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NRCA,Inc.

Head Start Program

1093 East Main Street

Radford, Va. 24141

Blacksburg Head Start

540.552.0490

Christiansburg Head Start

540.381.7559

MCPS

Virginia Preschool

Initiative

750 Imperial Street

Christiansburg, VA 24073

540.250.7416 or 540.382.5100 ext.1044

App. #

Verification of Birth ( ) Yes ( ) No Type of Document

Document #

Kindergarten Attendance Area:

___AES ___BEEKS ___BELVIEW ___CPS

___EMES ___FBE ___GLES ___PFES

Montgomery County Preschool Application - Virginia Preschool Initiative and NRCA Montgomery County Head Start

Child’s Information (first) (middle) (last) Child’s Full Name: Date of Birth: ( ) Male ( ) Female

Residence:

Mailing Address:

Directions to the home. Please include route numbers and significant landmarks.

Please list current and past preschool/Child Care programs your child has attended: Name of preschool/Child Care: _______________

Have you applied to another HS or VPI program for 2017 - 2018? ( Yes)__(_No)___

Mother/ Guardian Information

Name: Date of Birth: Lives with child: ( ) Yes ( ) No

Employer: Total Hours/Week: Work #:

Cell/Message Phone Number: E-mail address: ______________________________________

Father/Guardian Information

Name: Date of Birth: Lives with child: ( ) Yes ( ) No

Employer: Total Hours/Week: Work #:

Cell/Message Phone Number: E-mail address: _______________________________________

Others in Household (including all siblings)-(For Head Start Staff-Related by Blood, Marriage or Adoption) (Name) (Relationship to Child) (Date of Birth)

Does Your Child Have Insurance? Yes ( ) No( ) Please check all types of insurance that apply:

□Private Medical Insurance □ Private Dental Insurance □Medicaid

Date of child’s last physical: Date of child’s last dentist visit:

Are your child’s immunizations (shots) up to date? ( ) Yes ( ) No

Program Selection Please consider my child for the following program(s). I understand that there are limited spaces available in all programs. Please list 1st,

2nd, 3rd, 4th and 5th choices.

_____ Head Start full day services (serving 3 and 4 year olds)

_____ Montgomery County Public Schools Virginia Preschool Initiative (4 years old = full school day)

_____ New River Community College / Head Start full day services (Full time NRCC students only)

_____Head Start Part Day Services (4 days a week- Tuesday thru Friday mornings)

_____Children’s Health Improvement Partnership, Home-Visiting Program (provides in-home Parent Educator and Nurse visits)

**(CHIP serves pregnant mothers and those with at least one child in the home, 6 years old or younger)**

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Additional Family Information

1. Does your child have any special needs we should be aware of such as:

( ) Developmental Delay ( ) Speech /Language Disorders ( ) ODD, OCD, ADHD

( ) Autism ( ) Traumatic Brain Injury ( ) Visual Impairment

( ) Hearing Impairment ( ) Orthopedic impairment or physical limitations

2. Does your child receive special education services (related services), have a IFSP, or receive treatment from a doctor for

any of the above special needs? ( ) Yes ( ) No (if yes, staff please obtain release of information)

3. Does your child have a current IEP with Montgomery County Public Schools? ( ) Yes ( ) No

4. Does your child have any health problems, chronic conditions, or developmental concerns? ( ) Yes ( ) No If marked yes

please list and explain: (May use separate piece of paper)____________________________________________

______________________________________________________________________________________________________

5. In the past 12 months has the family experienced: domestic violence___ homelessness___ incarceration___ lack of food___

CPS involvement___ Is child a Foster Child (Y or N) drug/alcohol addiction___ Other traumatic event___ No answer__

6. Education/Training: (Complete only for parent/guardians living with child)

7. Work/School: (Please put checkmark in all boxes that apply for each)

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

( ) Yes ( ) No

8. Primary Language in household? ______________________________________________________________

9. Transportation: Not available in all specific locations only. Check with individual centers.

Available to transport?( ) Yes ( ) No To a bus stop?( )Yes ( )No

What prevents you from being able to transport your child? ________________________________________________

10. Your total annual family income: _$________________________

(Head Start and VPI will need verification of income from the past 12 months)

New River Community Action Head Start and Montgomery County 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, other children,

and family needs are noted. The following 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. By signing the application below, I authorize the release of all medical, dental, educational, and developmental

information to be shared by New River Community Action Head Start and Montgomery County Public Schools.

Parent /Guardian Signature Staff Signature Date

Mother /Guardian 1 Father /Guardian 2

No GED/Diploma (Last grade attended)

Has GED/Diploma

Some College/Associate’s Degree/ Other Training (Please Circle One)

Has College Degree (Bachelor’s or above) Please List Degree(s)

Mother/Guardian 1 Father/Guardian 2

Work 20 hours or less/week

Work 20-30 hours a week

Work 30+ hours a week

School part-time (# of hours) WHERE?

School full-time (# of hours) WHERE?

Preschool - Montgomery County Public Schools

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Montgomery County Public Schools750 Imperial Street, Christiansburg, VA 24073 | Phone: (540) 382-5100 | Fax: (540) 381-6127

Preschool

Montgomery County Public Schools » Departments » Curriculum & Instruction » Preschool

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Virginia Preschool Initiative

New VPI Application for 2017-2018. You may apply now!

Espanol Aplicacion 2017-2018! Emily Altizer - Supervisor of Preschool ProgramsPhone (540) 382-5100, extension 1044Email: emilyaltizer@mcps.org

The Virginia Preschool Initiative began in 1994 as a part of a program to improve educational achievement. This initiative serves at-risk four year olds who are not being served by Head Start. Students must be four years old by September 30 in order to be eligible for the program.

Preschool programs are located in eight elementary schools in Montgomery County:

Auburn ElementaryBelview ElementaryChristiansburg PrimaryEastern Montgomery Elementary (two classrooms)Falling Branch ElementaryGilb t Li k El t

Virginia Preschool Initiative

New VPI Application for 2017-2018. You mayapply now!

Espanol Aplicacion 2017-2018! Emily Altizer - Supervisor of Preschool Programs

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Preschool - Montgomery County Public Schools

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Montgomery County Public SchoolsEngage! Encourage! Empower!750 Imperial Street, Christiansburg, VA 24073Phone (540) 382-5100 | Fax (540) 381-6127

Montgomery County Public Schools does not discriminate in its programs and activities for reasons of race, religion, color, gender, national origin, disability, age, or on any other basis prohibited by law. Thefollowing persons have been designated to handle inquiries regarding non-discrimination policies:

Director of Human Resources and Director of Secondary Education 750 Imperial Street SE, Christiansburg, VA 24073 (540)382-5100

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Phone (540) 382-5100, extension 1044Email: emilyaltizer@mcps.org

The Virginia Preschool Initiative began in 1994 as a part of a program to improve educational

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