Head Start Application - Clinch Valley Community Action

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CVCA Head Start / Early Head Start / TCPSP Application

Serving Bland, Smyth, Tazewell and Wythe Counties

Dear Families:

Attached you will find an application for PreK (child must be 4 by September 30), Head Start (child must be 3 or 4 by September 30), and Early Head Start (child may be birth to age 3; pregnant women are also eligible). This application serves all three programs. A selection committee will make the determination as to your child’s placement. The selection committee will begin making placements during the first week of July from eligible applications and will continue to place children until all available slots are filled. Parents/guardians will receive
notification of their child’s placement during the first two weeks of August. No placement decisions will be discussed prior to this time, nor will any child be discussed with anyone other than the child’s parent or legal guardian.

Please remember that your child’s application CANNOT be processed without ALL the necessary documents.

These documents include:

• Proof of Income, completion of Homeless Form (with documentation of any household income), or No Income Form Check stubs need to be for the most recent 4 week period prior to completing the application or a W2 or Income Tax Forms may be used. If you receive TANF or SSI please provide documentation.

• Foster Care Documents (if applicable) – proof of income must be included in addition to these documents in order to determine eligibility for Pre K.

• Proof of Birth – Pre K applicants must provide a copy of child’s birth certificate with application; upon enrollment to the Pre K program the original birth certificate must be presented to the school staff member who is enrolling child. Head Start and Early Head Start may use a birth certificate or a birth letter for enrollment. If you do not have these items and need help obtaining them, please
contact the Tazewell County Pre-School Partnership for assistance.

• Two Items Documenting Physical Address

• If you indicate that you child has a current, diagnosed disability, please provide a copy of his/her IEP or IFSP with application.

Sincerely,

Tazewell County Pre-School Partnership

Child's Firstname

Middlename

Lastname

Date of Birth

Select Gender

MaleFemale

Physical Address

Mailing Addressif different from your physical address

Is your family currently homeless?

YesNo

Directions to Homeindicate route numbers and landmarks

0 /

Current and past preschool/Child Care programs your child has attended

0 /

Have you applied to another HS or VPI program for 2020 - 2021?

YesNo

Parent/Guardian #1your full name

Relationship to child

Date of Birth

Lives with child?

YesNo

Cell, Message phone #

Emaila valid email

Parent/Guardian #2your full name

Relationship to child

Date of Birth

Lives with child

YesNo

Cell, Message phone #

Others in household (list below):

0 /

Namefull name

Relationship

Birthdate

Namefull name

Relationship

Birthdate

Namefull name

Relationship

Birthdate

Does you child have insurance?

YesNo

Please check all types of insurance that apply

Private Medical InsurancePrivate Dental InsuranceMedicaid

Date of child’s last physical

Date of child’s last dental visit

Are your child’s immunizations (shots) up to date?

YesNo

Does your child have any special needs we should be aware of such as: (please mark all that apply)

Developmental DelaySpeech/Language DisordersODD, OCD, ADHD / ODD, TOC, TDAHTraumatic Brain InjuryVisual Impairment Hearing ImpairmentOrthopedic impairment or physical limitations Trauma

If trauma was selected, please explain:more details

0 /

Does your child receive special education services or related services (have an IFSP or IEP)?(If yes, staff will need a Release of Information.)

YesNo

Does your child have any chronic health conditions and/or developmental concerns they have seen a specialist for and/or prescribed medication?

YesNo

If marked yes please list and explain:more details

0 /

Is child a Foster Child

YesNo

Education/Training for Parent/Guardian 1(Complete only for parent/guardians living with child)

No GED/DiplomaHas GED/DiplomaSome College/Associate’s Degree/ Other TrainingHas College Degree (Bachelor’s or above)

If no GED/Diploma, list last grade attendedParent/Guardian 1

0 /

For college degree, list degreeParent/Guardian 1

0 /

Education/Training for Parent/Guardian 2(Complete only for parent/guardians living with child)

No GED/DiplomaHas GED/DiplomaSome College/Associate’s Degree/ Other TrainingHas College Degree (Bachelor’s or above)

If no GED/Diploma, list last grade attendedParent/Guardian 2

0 /

For college degree, list degreeParent/Guardian 2

0 /

Work/School for Parent/Guardian 1(Please put checkmark in all boxes that apply for each)

Not EmployedWork 29 hours or less a weekWork 30+ hours a weekSchool part-timeSchool full-time

If attending school, how many hours?Parent/Guardian 1

Work/School for Parent/Guardian 2(Please put checkmark in all boxes that apply for each)

Not EmployedWork 29 hours or less a week Work 30+ hours a weekSchool part-timeSchool full-time

If attending school, how many hours?Paent/Guardian 2

Do you receive housing assistance?(i.e. rental assistance, no monthly rent or mortgage payment, HUD or other subsidy)

YesNo

Need transportation?

YesNo

What prevents you from being able to transport your child?

Your total annual family income

How did you hear about the program?

Clinch Valley Community Action Head Start and Public Schools program takes into consideration a number of factors in order to determine eligibility. In addition to your income level and the age of your child, members in household, and family needs are noted. The information is voluntary. This information will be considered along with other information shared with our staff during the application process in order to determine eligibility and become familiar with your family.

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