Thank you for your interest in the Prince William County Schools Preschool Programs. Please include the following with your completed application forms:

1. Income VerificationFamily income documents such as:• TANF or SSI payment information, or• W-2 forms or pay stubs which indicate gross year-to-date earnings, or• Last year’s tax return (1040), or• An official letter from your employer stating your monthly earnings.• Also, documentation of child support or spousal support you receive.

2. Proof of Residency• Lease, rent agreement, Deed, or Mortgage statement• Two other forms of proof (utility bill, car registration, bank statement, etc.)

3. Child’s birth certificate copy

If you have questions or do not have all the above required items, please contact the Preschool office for assistance at 703-791-8708 or 703-791-8957.

Once the completed application and required documents are received by the Preschool office, you will be contacted to confirm receipt. Completed applications DO NOT guarantee a child’s acceptance into the Preschool Program. Selections are based on established enrollment criteria.

Thank you,

Preschool Program Staff

P.O. BOX 389, MANASSAS, VA 20108 • WWW.PWCS.EDU • 703-791-8708, FAX 703-791-8913

http:WWW.PWCS.EDU

CONFIDENTIAL Prince William County Schools Preschool Application

Preschool Child Information:All Sections Required

Parent/Guardian (1) Information: Father Mother Guardian/Other:

First Name: Last Name:

Birthdate: Gender:

Primary Language: Speaks English: Race:

First Name Last Name:

Birthdate: Gender: Race:

Mobile Phone #:

Carrier:

Work Phone: Employer Name:

Email: Work status:

Education level completed: Currently enrolled in school: Yes No

Primary Language: Speaks English:

Guardian/Other: Parent/Guardian (2) Information: Father Mother First Name Last Name:

Birthdate: Gender: Race:

Mobile Phone:

Carrier:

Work Phone: Employer Name:

Email: Work status:

Education level completed:

Currently enrolled in school: Yes No

Primary Language: Speaks English:

Address (if different from child):

Child’s Home Address:Street Address: Apt#

City: Zip Code: Base Elementary School:

Home Phone: Current Housing:

Housing Payment:

Mailing Address if Different from home address:

Family Information:Please check all the services your family currently receives: None

Child Care Assistance Public Housing (Section 8) Medicaid/Medicare

Energy/Fuel Assistance SSI Public Assistance/TANF

Foster Care Subsidy WIC SNAP/Food Stamps

Other: ____________ Child Support Unemployment Insurance

The following are risk factors that help the program determine the level of support families need. The following are confidential and answering yes will not limit your child’s access to services.

Please check all that relate to your child: None Child has no prior preschool or childcare experience Child has chronic health condition (asthma, diabetes, heart problems, other)Child has no health insurance Child needs medical treatment however parents are not able to access care Parent concern about child’s speech (check all that apply):

child does not speak others are not able to understand my child child learned to talk late chchild is not able to pronounce certain letters or sounds

I am not able to understand my child Other: People who live outside my home can not understand my child's speechA medical doctor has expressed concern about my child's speech or development.

Parent concern about child’s development (check all that apply):child is not able to walk or move easily child is not able to understand simple directions

c child does not respond to his/her name child is not able to identify his/her name Other:

Parent concern about child’s behavior explain:_______________________________________Parent concern about child’s emotional health explain:________________________________Child receives special education services (speech or development) currentlyChild received special education services in the past (as an infant or toddler)Child in foster care or kinship care Child was enrolled in Early Head Start (birth – 3 years old)Child has been exposed to violence, gang or drug use/sale in the home or community History of Child Protective Services involvement or services in the family

Teen Parent? (under 18 years when first child was born)

Child or family has moved once or more times a year?

How did you hear about the preschool program?

Other:

Household Information:

Number of Adults in family # ________ (18 years or older, residing in the home and supported by your income) Name: Date of Birth: Gender: Relationship to you:

Number of Children in family # _______ (17 years or younger, related by birth/marriage/adoption/custody) Name: Date of Birth: Gender: School/Grade (2020-21): Relationship to you:

Family Income Information:

Please list the current GROSS monthly income for your family (amount received before taxes).

Child Support

Social Security Payments

Public Assistance/TANF

Retirement

Employment Income

Un-Employment Payments

Foster Care Payments

Other Income

By signing below, I certify that the information provided is correct to the best of my knowledge and is subject to verification. I am aware that PWCS staff will verify documentation to determine my eligibility for the preschool program.

I am also aware that providing misleading information may result in termination from the program.

Parent Signature Print Name Date

Income verification required to process the application. Acceptable forms of income documentation are: o TANF/SSI payment information;o W-2 forms;o Current pay stubs which indicate gross year-to-date earnings;o Last year’s tax forms;o Child Support or Spousal Support documentation; ORo Official letter from your employer stating your monthly earnings

OFFICE USE ONLY

Application Received Date: ______________________ Staff Initials: ________________

Verifications Received: Income Address Birth Certificate (or proof of birth)

Type: ___________________ Type: ___________________ Verified birthdate: _________________

CONFIDENTIAL Prince William County Schools Preschool Application

Child’s Name: Date: Child’s Medical History

Physical Health YES/NO Comments 1. Does your child have health insurance? Type:

2. Does your child have a regular doctor? Name: Phone:

3. Does your child have:Asthma Diabetes Heart Problems

Seizures Other:

If yes, last time your child had an episode that required medication or Doctor’s visit:

4. Does child have any allergies:Foods:Bees/Insects:Other:

If “YES” has your child seen an allergist or had allergy testing?

Yes No

5. Does you give your child vitamins or supplements? If yes, what?

Dental Health YES/NO Comments 6. Has your child seen a dentist?

Dentist Name: 7. Does your child use a baby bottle?

8. Are there any dental problems that have not beentreated? (cavities, tooth pain)9. Do you live in an area where the water supply is notfluoridated (well water)?

If “YES” does child take a fluoride supplement?

10. Does your child eat or chew things that are not food?

Nutrition How often does your child eat from the following food groups (per day)?

Grain (cereal, bread, tortillas, rice and/or pasta)?

Protein (beef, chicken, fish, beans, eggs and/or peanut butter)?

Dairy (milk and/or eat yogurt or cheese)?

Vegetables (carrots, broccoli, green beans, squash, tomatoes and/or potatoes)?

Fruits (oranges, apples, bananas, kiwis and/or grapes)?

Water?

Fruit juice, soda, or sports drinks?

What type of milk does your child drink? If other specify:

YES/NOPork Are there any foods your child should not eat for religious or

personal reasons?

If yes, what? Are there any foods your child should not eat for medicalreasons?

Nutrition & Menu Concerns Check foods your child should not eat:

Shelfish FishBeefOther:Non-Halal Meats

Click to Print Click to Save Click to Submit Click to Clear/Reset

Household Information:Household Information:Family Income Information:Family Income Information:By signing below, I certify that the information provided is correct to the best of my knowledge and is subject to verification. I am aware that PWCS staff will verify documentation to determine my eligibility for the preschool program.By signing below, I certify that the information provided is correct to the best of my knowledge and is subject to verification. I am aware that PWCS staff will verify documentation to determine my eligibility for the preschool program.

Income verification required to process the application.Income verification required to process the application.Child’s Name: Date:Child’s Name: Date:

Parent Application Eng 2019 Word try one 2 after.pdfHousehold Information:Household Information:Family Income Information:Family Income Information:By signing below, I certify that the information provided is correct to the best of my knowledge and is subject to verification. I am aware that PWCS staff will verify documentation to determine my eligibility for the preschool program.By signing below, I certify that the information provided is correct to the best of my knowledge and is subject to verification. I am aware that PWCS staff will verify documentation to determine my eligibility for the preschool program.

Income verification required to process the application.Income verification required to process the application.Child’s Name: Date:Child’s Name: Date:

Check Box63: OffCheck Box64: OffCheck Box65: OffSpecify what behavior concern you have: Specify what emotionsl health concern you have: Child's First Name: Child's Last Name: Primary Language: Parent's Name: Parent's Last Name: Parent's Birthdate: Mobile Phone #: Parent's Work Phone: Parent's Email: Parent Primary Language: Parent's Name2: Parent's Last Name2: Parent's Birthdate2: Address if different from child: Street Address: Apt: City: Zip Code: Base Elementary School: Mailing Address if Different from home address: Check Box1: OffCheck Box2: OffCheck Box3: OffGuardian/Other: Speaks English: [ ]Child's Race: [ ]Parent's Gender: [ ]Parent's Race: [ ]Mobile Carrier: [ ]Parent's Employer Name: Parent's Speaks English: [ ]Parent's Education Level: [ ]Check Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7: OffCheck Box8: OffGuardian/Other2: Parent's Gender2: [ ]Parent's Race2: [ ]Mobile Phone2 #: Parent's Work Phone2: Parent's Employer Name2: Parent's Email2: Mobile Carrier2: [ ]Current Housing: [ ]Parent's Education Level2: [ ]Parent's Speaks English2: [ ]Parent Primary Language2: House Phone #: House Payment: [ ]Check Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffIf other, specify: Check Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box19: OffCheck Box24: OffHow did you hear about us?: [ ]Other3: Check Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffSpecify what speech concern you have: Check Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box39: OffCheck Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffSpecify what developmental concern you have: Check Box48: OffCheck Box52: OffCheck Box56: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box54: OffCheck Box53: OffChilds Name: Date_2: Type_3: If yes last time your child had an episode that required medication or Doctors visit: medication or Doctors visit: Other health issues: If YES has your child seen an allergist or had allergy testing Yes No: If yes what: If YES does child take a fluoride supplement10 Does your child eat or chew things that are not food: If yes what_2: Health Insurance: [ ]Primary Doctor: [ ]Health Issues: [ ]Any Allergies: [ ]Take vitamins: [ ]Seen a dentist: [ ]Dental problems: [ ]Water supply: [ ]Eat or Chew things: [ ]Baby bottle: [ ]Check Box57: OffCheck Box58: OffCheck Box60: OffCheck Box59: OffCheck Box61: OffCheck Box62: OffFood Allergy: Bees/Insects: Other Allergies: Juice or drinks: [ ]What type of milk?: [ ]Other milk: for religious or personal reason: [ ]Medical reason: [ ]Check Box66: OffCheck Box67: OffAllergies to other food: If YES does child eat or chew things that are not food: Check Box55: OffEmployment Income: Un-Employment Payments: Foster Care Payments 1: Other Income: Date: OFFICE USE ONLY: Check Box100: OffCheck Box102: OffCheck Box101: Off# of Adults: Parent's Complete Name: Name 2: Name 3: Parent's Birthdate3: Relationship to you 1: Date of Birth 2: Date of Birth 3: Relationship to you 2: Relationship to you 3: # of children: Child's First Name2: Child's Birthdate: Child's Gender: [ ]School Grade 2019-2020: Relationship to you: Name of the child 2_2: Name 3_2: Name 4: Name 5: Date of Birth 2_2: Date of Birth 3_2: Date of Birth 4: Date of Birth 5: 1: 2: 3: 4: 2_2: 2_3: 2_4: 2_5: Print Name: Signature: Parent's Gender5: [ ]Parent's Gender4: [ ]Parent's Gender6: [ ]Child's Gender3: [ ]Child's Gender4: [ ]Child's Gender5: [ ]Parent's Work Status: [ ]Check Box68: OffPhone: Child Support: Social Security Payments: Public AssistanceTANF 1: Retirement: Grain: [ ]Protein: [ ]Dairy: [ ]Vegetables: [ ]Fruits: [ ]Water: [ ]Parent's Work Status2: [ ]Child's Birthdate2: Name of doctor: Does your child use a baby bottle: Dentist Name: Are there any dental problems that have not been treated cavities tooth pain: PRINT: Save: Child's Gender2: [ ]Child's Gender2 2: [ ]Submit: Clear: