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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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