LABEL #: PK20____________________  

SCHOOL _________________________

Chesterfield County Public Schools PreK Program Application 

Completion of this application does not guarantee acceptance into the PreK program. Accepted applicants will be notified.

Today’s Date: __________________________ School: _____________________________________________ 

 

Child’s Full Name: _______________________________ _________________________________ ________ Circle One: Male Female

LAST NAME FIRST NAME MI

Child’s DOB:  

Month _________ Day __________ Year ___________ Child’s current age: _____________

Birth Mother’s Age on Child’s 

Birth Certificate 

MOTHER’S AGE WHEN CHILD WAS BORN: ________________

Does the child have a disability 

or special need? Circle One: YES NO If yes, describe:

Does the child have a current 

IEP (Individualized Education

Plan)? 

Circle One: YES NO If yes, describe:

Where does your child receive services? ________________________________

Does the child have a speech or 

language problem? 

Circle One: YES NO If yes, describe:

Does the child receive speech or language services? YES NO

If yes, where does your child receive services? __________________________________

Primary language spoken in the 

home 

 

Circle One: English Other (specify language): ________________________

What is your child’s primary language? _____________________________________

Does your child have a sibling 

that attended a Public School 

PreK program? 

Circle One: YES NO If yes: Name of school ____________________________

County or city ______________________________

Your child lives with  Both Parents Mother Father Stepparent Legal Guardian Grandparent Foster Parent

Other: (Describe:_________________________)

 

Family Characteristics: (Circle ALL that apply) 

Single Parent Separation or Divorce-Describe:

Physical/Mental Illness in the Home Death in Immediate Family (within the last year)

Relationship to child: ______________________________

Lack of Stable Housing (moved more than 3 times in the past 4

years)

Family Counseling

Current Military Deployment of Parent Smoking in the Home

Child NOT Covered by Health Insurance

NONE OF THESE APPLY TO MY CHILD 

 

Did or Does your child have any of the following characteristics? (Circle ALL that apply) 

Speech or Hearing Condition Destructive or Violent Behavior

Health Condition Developmental Delay

Low Birth Weight Other, please describe:

NONE OF THESE APPLY TO MY CHILD 

Chesterfield County Public Schools does not unlawfully discriminate on the basis of sex, race, color, age, religion,

disability or national origin in employment or in its programs and activities.

 

LABEL #: PK20____________________  

Completion of this application does not guarantee acceptance into the PreK program. Accepted applicants will be notified.

Additional Family Characteristics: (Circle ALL that apply) 

Incarceration of Parent: Which parent?______________________ Exposure to Domestic or Community Violence

Deportation of Parent: Which parent? ______________________ Maternal Substance Abuse During Pregnancy

Physical Abuse Child Being Raised by Someone Other than a Parent (not foster parent)

Sexual Abuse Currently experiencing homelessness (living in or with: street, car, 

hotel, friends, relatives) 

Alcohol/Substance Abuse NONE OF THESE APPLY TO MY CHILD 

Mother’s Highest Education 

Level COMPLETED 

Circle One: K-5 6-8 High School/GED Some college/Vocational Degree

Associate’s Degree Bachelor’s Degree Master’s Degree Doctorate or Professional

Degree

Father’s Highest Education 

Level COMPLETED 

Circle One: K-5 6-8 High School/GED Some college/Vocational Degree

Associate’s Degree Bachelor’s Degree Master’s Degree Doctorate or Professional

Degree

Is the Mother Hispanic? Circle One: YES NO

Mother’s Race 

 

Circle One: American Indian/Alaskan Native Asian Black/African American

Native Hawaiian/Pacific Islander White Two or More Unknown

Mother’s Employment Status Circle One: Full Time Part Time Unemployed Taking Classes/Training

Father’s Employment Status Circle One: Full Time Part Time Unemployed Taking Classes/Training

Number of Parents (including

Stepparents) Living at the Address  ___________ 

Number of Siblings (INCLUDING

the PreK applicant child) Living at the 

Address  

___________

List the names and ages of 

these children (INCLUDING the

PreK applicant child)  

 

PreK Applicant Name _____________________________ Age _________________ 

 

Siblings’ Names __________________________________ Age _________________ 

 

__________________________________ Age _________________ 

 

__________________________________ Age __________________ 

Free and Reduced Meals? Please provide the name and school of any sibling that currently receives free and reduced meals.

Sibling’s name ____________________________ School ___________________________________ 

 

*PLEASE READ BEFORE SIGNING… 

I certify that all the information on this application is true and all income is reported. I understand if any of this information changes, I am obligated to

notify the program immediately. I understand deliberate misrepresentation of any of this information may subject me to prosecution under applicable

State and Federal laws. I understand misinformation may subject my child to be excluded or removed from the program. I further understand that

completion of all application information (including physical examination, immunizations, birth certificate, proof of residence, proof of income, etc.) is

required.

*Signature of Parent/Guardian: ____________________________________________ Date Signed: __________________________________

Chesterfield County Public Schools does not unlawfully discriminate on the basis of sex, race, color, age, religion,

disability or national origin in employment or in its programs and activities.

Chesterfield County Public Schools Student Registration Form

Student’s Full Legal Name (Exactly as shown on birth certificate) Grade: ____ PRE K ID#___________________________________

__________________________________________________________________________________________ Legal Last Name Legal First Name Legal Middle Name Suffix

Date of birth: _____ _____ ______ Birth Certificate #___________________ Gender: Male Female Month Day Year

Country of Birth________________ State of Birth____________________ City of Birth______________________

Is the student an Immigrant? Yes If yes entry date in U.S. Schools _____________ No Immigrant – Individuals who are school aged 3 through 21; were not born in any State of the United States of America (including Puerto Rico and D.C.); and have not been attending one or more schools in any one or more States for more than three (3) full academic years.

Primary Language Spoken: What is the primary language used in the home, regardless of the language spoken by the student?_______________________________________________________

What is the language most often spoken by the student?__________________________________________________________________________________________

What is the language that the student first acquired?_____________________________________________________________________________________________

If Language other than English contact the ESOL Welcome Center

Ethnic Group- The US Department of Education requires that both these questions be answered and provides only the following categories for ethnic group and

race. If both questions are not answered, school personnel are required to make selections for both.

Is the student Hispanic or Latino? No - Not Hispanic or Latino Yes - Hispanic or Latino

Race: Select all that apply

American Indian or Alaska Native Asian Black/African American White Native Hawaiian or Other Pacific Islander

******************************************************************************************************* Primary Address of Student/ Enrolling Parent Relationship: Mother Father Legal Guardian Foster Parent Other______________________

Last Name First Name Middle Initial Suffix Address________________________________________________________________ City____________________________ State_______ Zip_________________ Home Phone Number _______________________________ Cell Number ________________________________ Work Number_____________________________

Mailing address (if different from primary address) ______________________________________________________________________________________________ Address . City State Zip

Parent Email Address_____________________________________________________________________________________________________________________

Contact Allowed: Yes No Educational Rights: Yes No Custody: Yes No Student Lives with: Yes No Release To: Yes No Preferred method of contact: English Spanish Other ______________________________________

Other Parent Relationship: Mother Father Legal Guardian Foster Parent Other_____________________

_______________________________________________________________________________________________________________________________________ Last Name First Name Middle Initial Suffix Address ______________________________________________________________ City ________________________ State _________ Zip__________________ Home Phone Number _________________________________ Cell Number_______________________________ Work Number_____________________________ Email Address____________________________________________________________________________________________________________________________ Contact Allowed: Yes No Educational Rights: Yes No Custody: Yes No Student Lives with: Yes No Release To: Yes No

Student Name_____________________________________

Other Parent Relationship: Mother Father Legal Guardian Foster Parent Other____________________

_______________________________________________________________________________________________________________________________________ Last Name First Name Middle Initial Suffix Address_______________________________________________________ City ___________________________________ State _______ Zip__________________ Home Phone Number__________________________________ Cell Number______________________________ Work Number_______________________________ Email Address____________________________________________________________________________________________________________________________ Contact Allowed: Yes No Educational Rights: Yes No Custody: Yes No Student Lives with: Yes No Release To: Yes No

Other Parent Relationship: Mother Father Legal Guardian Foster Parent Other_____________________

_______________________________________________________________________________________________________________________________________ Last Name First Name Middle Initial Suffix Address ______________________________________________________ City ____________________________________ State _______ Zip__________________ Home Phone Number __________________________________ Cell Number____________________________ Work Number________________________________ Email Address ___________________________________________________________________________________________________________________________ Contact Allowed: Yes No Educational Rights: Yes No Custody: Yes No Student Lives with: Yes No Release To: Yes No

Other Parent Relationship: Mother Father Legal Guardian Foster Parent Other______________________

_______________________________________________________________________________________________________________________________________ Last Name First Name Middle Initial Suffix Address ______________________________________________________City _____________________________________ State _______ Zip__________________ Home Phone Number __________________________________Cell Phone ____________________________ Work Number_________________________________ Email Address ___________________________________________________________________________________________________________________________ Contact Allowed: Yes No Educational Rights: Yes No Custody: Yes No Student Lives with: Yes Release To: Yes No

**Emergency Contact** Relationship: Grandparent Friend Neighbor Other_________________________________

Last Name _____________________________________________________ First Name __________________________________________________ Middle Initial __ Home Phone Number ______________________________________Cell Number____________________________ Other Number____________________________

Permission to Release Student to Emergency Contact Yes No

Court Order Information

Does your child have court restrictions regarding a parent/legal guardian contact? Yes No (If yes, please provide copy of court documents)

Date of Order:____________________ Court Order Type:______________________________ Order Locality:______________________________

Student educational records and/or student will be released to parent/guardian unless a court order specifically prohibits contact or release with parent/guardian. Enrolling parent/legal guardian is responsible for providing current copies of all court orders.

Student Name_____________________________________

Additional Student Information

Special Placement Is the student in Foster Care? Yes No If yes, name of placing agency:_______________________________________ Does the student reside in a group home/foster home? Yes No Name of Group Home_____________________________________________________________________________________ Social Worker’s Name:____________________________________________ Social Worker’s Number:___________________

Special Instructional Placement Does the student have an active 504 Plan? Yes No (If yes, please provide copy of 504)

Does the student have an active IEP? Yes No (If yes, please provide copy of IEP)

Transportation Will the student ride a CCPS bus to /from school? Yes No Will the student ride a daycare bus? Yes No Provider Name:____________________________ Prior School Enrollment Has the student previously attended Chesterfield County Public Schools? Yes No CCPS school previously attended:_________________________________________________________ Grade ______ What school division is student transferring from?___________________________________________ What school is student transferring from? __________________________________________________ Grade level at previous school_________ First time in 9th grade? Yes No If no, ______________________ School year attended

For School Personnel Only School:_________________________________ Responsible School _____ Serving School_____ Program Code:____ Waiver Status:__________ Bus #_____ Entry Code______ Date__________

For School Personnel Only

Birth Certificate Notarized Affidavit

Immunization Yes No Physical Yes No

For School Personnel Only Proof of Residency Provided Yes No Date Provided______________________

Deed Current Signed Lease

Residency Review Status: 30 day 60 day 90 day Annual School Personnel Initials _____________

Proof of Residency (8/09) AAA-1418 revised

CHESTERFIELD COUNTY PUBLIC SCHOOLS

Parents, legal guardian, or person acting in place of the parent, please complete this form, have it notarized, and return it to the school serving your attendance zone. Date: ________________ School: ___________________________________ For School Year: __________

I, _____________________________________, Parent, legal guardian,

own/rent/lease housing and reside with: (Student’s name)________________________________________________ at: (Street Address) ___________________________________________________________________________________ (City/County) ______________________________________________, (State) _VA _ (Zip) ___________________ Telephone: (Home) _____________________ (Work) _____________________ (Cell) __________________ For the purpose of establishing residency in Chesterfield County, the parent, legal guardian, or person acting in place of the parent shall provide one of the following documents in the name of that individual:

1. lease for a period of at least one year of a residence located in Chesterfield; 2. deed to a residence located in Chesterfield; 3. contract or lease free of contingencies to occupy a Chesterfield residence within two months of the date

of enrollment; 4. residence manager’s letter on company letterhead stating residence is a corporate residence located in

Chesterfield; or

5. weekly receipts for temporary residence in a hotel or motel for up to 60 days (will require renewal or evidence of more permanent residency within 60 days of enrollment).

Are you living in a motel, hotel or trailer on a temporary basis due to the

lack of adequate housing? Yes No

*When the student is living with someone other than his/her natural parent or a parent by legal adoption, the person with whom the student is living shall provide: (1) a personal written statement explaining the reasons why the student cannot be cared for by the parents and (2) Independent verification or substantiation of the family circumstances from an appropriate professional or agency such as proof of incarceration, doctor's statement, or investigative statement by child protective services, etc.

The sufficiency of the documentation provided with each enrollment application shall be determined by the

school division administration in accordance with controlling policy and regulations .

Certification. I hereby certify that all of the above information is true and correct, and I agree and understand that any falsification of information may result in the immediate removal of my child/children from the Chesterfield County Public Schools. I also agree and understand that any falsification of information will make me responsible for paying full nonresident tuition for my child/children from the date of enrollment in the Chesterfield County Public Schools. I further understand that should a principal have reason to believe that my residency status has changed, I may be required to submit a new proof of residency and that failure to do so may result in the immediate removal of my child/children from Chesterfield County Public Schools. I hereby agree to release this information to be verified. WARNING: Providing false information for school enrollment purposes is a criminal offense. VA Code 22.1-264.1.

________________________________________ ________________ Signature of Parent/Guardian/Custodian Date In the City/County of ___________________________________ in the Commonwealth of Virginia, the statements hereon have been sworn to and subscribed before me this _____ day of ________________, in the year _______. Witness my hand and official seal: _________________________________________

Notary Public My commission expires: ______________ Date

person acting in place of parent*

Lives with Form (8/11) AAA-1418A

CHESTERFIELD COUNTY PUBLIC SCHOOLS

Homeowners/leaseholders and parents, complete this form when student and parents live with others. Please have this form notarized, and return

it to the school serving your attendance zone. A new form must be completed at the beginning of every school year.

Date: __________School:__________________________________________ For School Year:________________________

I (Name of Resident) ___________________________________________________________________ own/rent/lease housing and reside at:

(Street Address)________________________________________________________________________________________ ______________

(City/County) ___________________________________________ , (State) ____ VA _______ (Zip)__________________

Telephone: (Home) _______________________ ______(Work) _______________________________ (Cell)________________________________

and hereby certify that the following persons reside with me at the address shown above:

Parent's/Guardian's Name ________________________________________Student's Name______________________________________________

I understand that enrollment of the student named above is based on my certification and that if this certification is false I may be liable for payment of

tuition for the student. I also agree to notify the school principal of any change in the residency of the above named student within three days of such

notice. WARNING: Providing false information for school enrollment purposes is a criminal offense. VA Code 22.1-264.1.

Homeowners/leaseholders, to establish your residency in Chesterfield County, please provide one of the following in your name:

1) lease for one year; 2) deed 3) contract or lease free of contingencies to occupy a Chesterfield residence within two months of the date of

enrollment; 4) residence manager's letter on company letterhead stating residence is a corporate residence located in Chester field; or 5) weekly

receipts for temporary residence. NOTE: refer to form AAA-1418 for detailed list.

Parent/guardian should provide an apartment manager’s letter on letterhead stating residence of the parent. Parent/guardian provides two of the

following within 30 days of enrollment:

1. utility bills for most recent two months that may include water, gas, electricity, cable, or telephone;

2. vehicle-related documents that may include registration, insurance policy or paid insurance bill;

3. employment verification that may include current payroll stubs, current employer verif ication on company letterhead, or similar documents

deemed acceptable by the school principal;

4. tax document that may include current forms of IRS-1099, IRS-1040, IRS-W2, IRS-W4;

5. other official correspondence from a government agency;

6. medical bills dated within past three months; or

7. consecutive bank statements from the last two months.

The sufficiency of the documentation provided with each enrollment application shall be determined by the school division adm inistration in

accordance with controlling policy and regulations.

Parent/Guardian:

Are you presently sharing the housing of other persons due to loss of housing, economic hardship, eviction, or displacement?

Yes No

Certification. I hereby certify that all of the above information is true and correct, and I agree and understand that any falsification of

information may result in the immediate removal of my child/children from the Chesterfield County Public Schools. I also agree and

understand that any falsification of information will make me responsible for paying full nonresident tuition for my child/children from the

date of enrollment in the Chesterfield County Public Schools. I further understand that should a principal have reason to believe that my

residency status has changed, I may be required to submit a new proof of residency and that failure to do so may result in the immediate

removal of my child/children from Chesterfield County Public Schools. I hereby agree to release this information to be verified. WARNING:

Providing false information for school enrollment purposes is a criminal offense. VA Code 22.1-264.1.

______________________________________ ____________ __________________________________________ _______ ______

Signature of Owner/Renter/Lessee Date Signature of Parent/Guardian/Custodian Date

In the City/County of _______________________________ in the Commonwealth of Virginia, the statements hereon have been sworn to and

subscribed before me this ________day of ______________, in the year _______.

Witness my hand and official seal: ______________________________________ My commission expires: _____________

Notary Public Date

Should a principal have reasonable suspicion during the school year that your residency status has changed, you may be requir ed to complete a new form.