Gaston County Schools Pre-Kindergarten Program APPLICATION
|
|
- Lorraine Hancock
- 8 years ago
- Views:
Transcription
1 Gaston County Schools Pre-Kindergarten Program APPLICATION Name of Child: First Middle Last Child s Gender: Circle one BOY GIRL Child s of birth Birthplace Month/Day/Year Is the child Hispanic? Circle one. YES NO Child s Race: Check all that apply. White/European American Hawaiian or Other Pacific Islander Native American Indian or Alaska Native Black or African American Asian Family/child s Address (Street) (City, State, Zip Code) County of Residence: Best telephone #s to reach you: please list two numbers Child lives with: Check all that apply Mother only Other: please specify Family size: _ This should include parents/step-parents, minor brothers/sisters, half brothers/sisters, step-brothers/sisters living in the home with the child (DOES NOT INCLUDE GRANDPARENTS, FIANCES, AUNTS/UNCLES, ETC.) 1
2 Mother/Stepmother/Guardian s Name (please provide even if not in the home) Mother/stepmother/guardian employed? YES NO Average hours worked per week: _ IF NOT WORKING is : Seeking employment Attending secondary education Attending high school/ged Attending job training Other employment Enter all income for Mother/Stepmother/Guardian: (Circle applicable pay period for each category reported) Current Wages BEFORE Taxes yearly monthly twice monthly bi-weekly weekly Alimony yearly monthly twice monthly bi-weekly weekly Child Support yearly monthly twice monthly bi-weekly weekly Workers Comp yearly monthly twice monthly bi-weekly weekly Unemployment yearly monthly twice monthly bi-weekly weekly SSI/TANF/Work First yearly monthly twice monthly bi-weekly weekly Overtime yearly monthly twice monthly bi-weekly weekly Father/Stepfather/Guardian s Name (please provide even if not in the home) Father/stepfather/guardian employed? YES NO Average hours worked per week: _ IF NOT WORKING is: Seeking employment Attending secondary education Attending high school/ged Attending job training Other employment Enter all income for Father/Stepfather/Guardian: (Circle applicable pay period for each category reported) Current Wages BEFORE Taxes yearly monthly twice monthly bi-weekly weekly Alimony yearly monthly twice monthly bi-weekly weekly Child Support yearly monthly twice monthly bi-weekly weekly Workers Comp yearly monthly twice monthly bi-weekly weekly Unemployment yearly monthly twice monthly bi-weekly weekly SSI/TANF/Work First yearly monthly twice monthly bi-weekly weekly Overtime yearly monthly twice monthly bi-weekly weekly INCOME VERIFICATION IS REQUIRED FOR ALL SOURCES OF COUNTABLE INCOME You are required to submit income verification (may be recent pay stub, tax records, award letter from Social Security Administration, award letter from Employment Security Commission, employer statements, business records for those selfemployed, signed statement when there is no verifiable countable income) Excluded from regular gross income are parent, step-parent and child Supplemental Security Income, adoptive assistance, foster care payments, and irregular income (e.g. overtime, temporary unemployment pay, Work First, Food Stamps, student loans) If you are a legal custodian, or other caregiver, only count child s income, including Social Security Income and Child Support Payments. Do not count Supplemental Security Income. Count income from any minor siblings living in the home. If legal guardian, and both biological parents are deceased or their parental rights have been terminated by the court, count the adult s income, child s income, including Social Security Income and Child Support Payments. Count income from any minor siblings living in the home. Do not count Supplemental Security Income. I certify that I have NO verifiable countable income. Mother/Stepmother/Guardian Signature Father/Stepfather/Guardian Signature 2
3 INFORMATION ABOUT YOUR CHILD: 1. The primary language spoken in our home is: English Other 2. Does your child have any identified, chronic health problem(s) diagnosed by a health care provider that may affect his/her school attendance? YES NO If yes, please describe and be prepared to provide documentation from the child s doctor. 3. My child has a current IEP (Individualized Education Program). YES NO If yes, what is/are the identified disability (or disabilities)? What special services or therapies does your child receive? Where does your child receive services/therapies? _ 4. Is at least one parent or legal guardian of this child an active duty member of the military, or was a parent or legal guardian of this child seriously injured or killed while on active duty? YES NO My child is currently in daycare, childcare, or attends a pre-k program. YES NO Name of daycare center City, State Do you currently receive daycare vouchers? YES NO Has your child ever been in childcare, day care, or preschool? YES NO If yes, name/location of center Does your child have any known allergies? No Yes Explain: Please give any information concerning your child which will be helpful in his experience in a group setting (such as play, eating and sleeping habits, educational concerns, special fears, special likes or dislikes). Also, tell us about your child, including any medical conditions or concerns, etc. and let us know of any family situations that we need to be aware of- such as someone who is NOT to pick your child up without your permission, etc. If there is a court order regarding custody of or visitation privileges for your child, please provide the pre-k staff with a copy for the file. EMERGENCY CARE INFORMATION: (MUST BE COMPLETED) Name of Child s Doctor Office Phone_ Name of Child s Dentist Office Phone_ Hospital Preference: Caromont Regional Medical Center Telephone: Other Hospital Preference Telephone: My child has: circle one MEDICAID NO HEALTH INSURANCE Private Health Insurance: Carrier Policy # 3
4 If neither mother nor father (or guardian) can be contacted, the following persons may be called: YOU MUST COMPLETE FOR TWO PERSONS OTHER THAN MOTHER/FATHER/GUARDIAN. Name Best Number to call Name Best Number to call Relationship to Child_ Alternate Number Relationship to Child_ Alternate Number If you cannot pick up your child, please give the FULL names of persons to whom the child can be released: I agree that the operator may authorize the physician of his/her choice to provide emergency care in the event the neither I nor the family physician can be contacted immediately. Signature of Parent I, as operator, do agree to provide transportation to an appropriate medical resource in the event of emergency. In an emergency situation, other children in the facility will be supervised by a responsible adult. I will not administer any drug or medication without specific instructions from the physician or the child s parent, guardian, or full-time custodian. Provisions will be made for adequate and appropriate rest and outdoor play. Signature of Operator Names and Ages of Brothers/Sisters of the Preschooler: How will your child be coming to school in the morning? School bus Car Daycare van How will your child be going home in the afternoons? School bus Car Daycare van If your child is placed in a pre-k classroom, the child s health assessment and certified birth certificate are expected by the first day of attendance. I certify that the information submitted in this application is true and correct. Name 4
5 Gaston County NCPK Program has pre-k classrooms located at the following sites. All sites are FREE, including private childcare sites. Please mark all sites that may be of interest to you in the order of your preference (1, 2, 3, or more). Income is considered for eligibility and placement at sites marked with asterisks (**). Children may ride the school bus ONLY if you live in the attendance district. Private sites do not usually provide transportation (check with individual private site.) 1 st Choice for Pre-K _ Elementary School District that child resides in _ # Choice Pre-K Site Location H. H. Beam Elementary South area Bessemer City Primary Bessemer City Brookside Elementary** North New Hope Road area Carr Elementary Dallas Catawba Heights Elementary** North Belmont area Chapel Grove Elementary** Chapel Grove area-s. Cherryville Elementary** Cherryville Costner Elementary** Dallas-Cherryville area Forest Heights Elementary West Gardner Park Elementary Lingerfeldt Elementary South area North Belmont Elementary Belmont Abbey area Page Primary School Belmont Pinewood Elementary** Mt. Holly Pleasant Ridge Elementary Rankin Elementary** Mt. Holly Robinson Elementary** Sadler Elementary West Sherwood Elementary Springfield Elementary** Stanley Tryon Elementary** Bessemer City-Cherryville area Woodhill Elementary A Toddler Tech** Bright Futures Learning Center** Childcare Network #99** Childcare Network #144** Carolina Kids Club** Cline Learning Center- Dallas** Cline Learning Center IV- Dallas** Gina s Kidsfirst** Kingdomz School of Excellence** New Hope for Kids** New Horizons** Preschool Connection** Smart Kids** The Grace School** 1223 Craig St.,, NC 188 Main St., McAdenville, NC 3092 Union Road,, NC 310 R. L. Stowe Road, Belmont, NC 4311 Titman Road,, NC 4334 Dallas Cherryville Hwy. Bess. City, NC 611 E. Trade St., Dallas, NC 2437 Redbud Drive,, NC 610 Radio Street,, NC 204 Stroupe Road,, NC 818 S. Church St.,, NC 301 Beaty Rd., Belmont, NC 740 Cox Road,, NC Lucia Riverbend Hwy., Stanley, NC 5
Gaston County Schools Pre-Kindergarten Program 2016-2017 APPLICATION
Gaston County Schools Pre-Kindergarten Program 2016-2017 APPLICATION Name of Child: First Middle Last Child s Gender: Circle one BOY GIRL Child s of birth Birthplace Month/Day/Year Is the child Hispanic?
More information2014-2015 Iredell County NC Pre-Kindergarten Application
PARENTS: Please remove this top sheet and keep for your information! 2014-2015 Iredell County Parents/Families must complete this application to apply for NC Pre-Kindergarten Program (formerly the More
More information2015-2016 Iredell County NC Pre-Kindergarten Application
PARENTS: Please remove this top sheet and keep for your information! 2015-2016 Iredell County Parents/Families must complete this application to apply for the NC Pre-Kindergarten Program (formerly the
More informationSchool District of New Richmond 701 East Eleventh Street New Richmond, WI 54017 715.243.7411 Fax 715.246.3638 www.newrichmond.k12.wi.
701 East Eleventh Street New Richmond, WI 54017 715.243.7411 Fax 715.246.3638 www.newrichmond.k12.wi.us Starting School Date: Site Assigned: 4-Year-Old Kindergarten Registration 2015-2016 Office Use Only:
More informationWhite Earth Early Learning Scholarship Program Information about the program Household Size Gross income How to complete the application:
White Earth Early Learning Scholarship Program White Earth Child Care/Early Childhood Programs Funded by MN s Race to the Top Early Learning Challenge Grant Information about the program Use this application
More informationSchool District of New Richmond 701 East Eleventh Street New Richmond, WI 54017 715.243.7411 Fax 715.246.3638 www.newrichmond.k12.wi.
School District of New Richmond 701 East Eleventh Street New Richmond, WI 54017 715.243.7411 Fax 715.246.3638 Starting School Date: Site Assigned: 4-Year-Old Kindergarten Registration 2016-2017 Check one:
More informationMaple Heights City Schools
Maple Heights City Schools ENROLLMENT OFFICE 5740 Lawn Avenue Maple Heights, Ohio 44137 ENROLLMENT OFFICE Phone: 216.587.6100, Ext. 3701 CHANGE OF ADDRESS REGISTRATION PACKET USE THIS PACKET FOR A CHANGE
More informationWATONGA ELEMENTARY SCHOOL 900 North Leach Main Office: (580) 623-5248 P.O. Box 640 Facsimile: (580) 623-5238 Watonga, Oklahoma 73772
WATONGA ELEMENTARY SCHOOL 900 North Leach Main Office: (580) 623-5248 P.O. Box 640 Facsimile: (580) 623-5238 Watonga, Oklahoma 73772 Website: www.watongapublicschools.com 2014-2015 STUDENT ENROLLMENT INFORMATION
More informationPATHWAY II: Early Learning Scholarship Award
PATHWAY II: Early Learning Scholarship Award This section to be completed by the Regional Administration Office: Application Identifier #: Region: District # and Type: Child Identifier #: County: Child
More informationPATHWAY I: Early Learning Scholarship Application
-2014 PATHWAY I: Early Learning Scholarship Application This section to be completed by the Regional Administration Office: Application Identifier #: Region: District Number and Type: Is the Family Income
More informationT.E.A.C.H. Early Childhood North Carolina Bachelor s Practicum Only Scholarship Program Application
T.E.A.C.H. Early Childhood North Carolina Bachelor s Practicum Only Scholarship Program Application Date Social Security # Name Address City, State, Zip County Phone Number Home: ( ) Work: ( ) Email Date
More information9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof.
Dear Parent/Guardian: Children need healthy meals to learn. Your child s school offers healthy meals every school day. Your childr en may qualify for free meals or for reduced price meals. 1. DO I NEED
More informationYes. Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): _
Page 1 ~ Martin County Community Action, Inc. Head Start Program P.O. Box 806/415 E. Blvd. Suite 130 Williamston, NC 27892 (252) 789-4930 Fax: (252) 792-1838 DPlease bring proof of income, child's birth
More informationL E T T E R T O H O U S E H O L D
Free and Reduced Price School Meals Letter to Households Page 1 of 1 L E T T E R T O H O U S E H O L D Dear Parent/Guardian: School Year 2014 2015 * * * * * * * * * * * * * * * NEW THIS SCHOOL YEAR!!!
More informationCHARLOTTE-MECKLENBURG SCHOOLS
STUDENT PLACEMENT ENROLLMENT INFORMATION The following documents are required for enrollment: q Student Enrollment Form q Original Certified copy of student s birth certificate - hospital, souvenir or
More informationNEW JERSEY HOME ENERGY PROGRAMS. Home Energy Assistance Universal Service Fund Weatherization Assistance
NEW JERSEY HOME ENERGY PROGRAMS Home Energy Assistance Universal Service Fund Weatherization Assistance Home Energy Assistance (HEA)/Universal Service Fund (USF) and Weatherization Application Home Energy
More informationT.E.A.C.H. Early Childhood ALABAMA Bachelor Degree Scholarship Application for Child Care Center/Preschool Teachers
GENERAL INFORMATION: Social Security Number: - - Date: Name: Address: Apt #: City: State: Zip: County: Phone: Home: ( ) Cell: ( ) Work: ( ) Email Address: Date of Birth (mm/dd/yyyy): / / Gender: Female
More informationState Early Childhood Education Scholarship Application
State Early Childhood Education Scholarship Application Information about the program Use this application to apply for the State Early Childhood Education (ECE) Scholarships program. This program provides
More informationT.E.A.C.H. Early Childhood North Carolina Master s Degree/Emphasis in Early Childhood Leadership and Management Scholarship Application
T.E.A.C.H. Early Childhood North Carolina Master s Degree/Emphasis in Early Childhood Leadership and Management Scholarship Application Section I: Demographics for all applicants Date Social Security #
More informationTrumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925
Trumbull Career and Technical Center 528 Educational Highway Warren, Ohio 44483 Toll Free 1-866-737-6925 Dear Parent/Guardian: Children need healthy meals to learn. TCTC offers healthy meals every school
More informationWelcome to Latta Public Schools
Welcome to Latta Public Schools 2015-2016 Pre-K-4 th Online Enrollment Packet Forms Included: Enrollment Form Student Health Inventory Form Student Enrollment Questionnaire Home Language Survey Tribal
More informationHow To Get A Job At An Early Childhood Training Program
737 Union Avenue Memphis, TN 38117 P: (901) 333-5541 F: (901) 333-5750 TECTA Tuition Assistance Checklist for First Semester CDA Seeking Students 1. Complete Southwest Admissions Application at www.southwest.tn.edu/applyonline.htm.
More informationT.E.A.C.H. Early Childhood North Carolina Bachelor s Degree Scholarship Application
T.E.A.C.H. Early Childhood North Carolina Bachelor s Degree Scholarship Application Date Social Security # Name Address City, State, Zip County Phone Number Home: ( ) Work: ( ) Email Date of Birth Gender
More informationNEW JERSEY HOME ENERGY PROGRAMS. Home Energy Assistance Universal Service Fund Weatherization Assistance
NEW JERSEY HOME ENERGY PROGRAMS Home Energy Assistance Universal Service Fund Weatherization Assistance Home Energy Assistance (HEA)/Universal Service Fund (USF) and Weatherization Application Home Energy
More informationAPPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS
Capital Advantage Insurance Company Commonwealth of Pennsylvania Edward G. Rendell, Governor APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS Application Information The information
More informationT.E.A.C.H. Early Childhood MISSISSIPPI Associate Degree Scholarship Application for Child Care Center Teachers
GENERAL INFORMATION: Social Security Number: - - Date: Name: Address: Apt #: City: State: Zip: County: Phone: Home: ( ) Cell: ( ) Work: ( ) Email Address: Date of Birth (mm/dd/yyyy): / / Gender: Female
More informationDear Homeowner: Thank you for your interest in The Opportunity Alliance Home Repair Network. The first step is to determine if you pre-qualify.
Dear Homeowner: Thank you for your interest in The Opportunity Alliance Home Repair Network. The first step is to determine if you pre-qualify. On the subsequent pages, you will find the application for
More informationHealth Coverage & Help Paying Costs Application for One Person
THINGS TO KNOW Health Coverage & Help Paying Costs Application for One Person Use this application to see what insurance choices you qualify for Free or low-cost insurance from Medicaid or the Kentucky
More informationT.E.A.C.H. Early Childhood Alabama Associate Degree Scholarship Application for Family Child Care Home Providers
GENERAL INFORMATION: Social Security Number: - - Date: Name: Address: Apt #: City: State: Zip: County: Phone: Home: ( ) Cell: ( ) Work: ( ) Email Address: Date of Birth (mm/dd/yyyy): / / Gender: Female
More informationA String Theory School
A String Theory School www.stringtheoryschools.com West Campus Vine Street Campus East Campus 2600 South Broad Street 1600 Vine Street 2407 South Broad Street Philadelphia, PA 19145 Philadelphia, PA 19102
More informationBirth to Three, Then What?: Early Interventions role in the inclusion of children with Down syndrome
Birth to Three, Then What?: Early Interventions role in the inclusion of children with Down syndrome Thank you for taking the time to complete this survey. Your answers are very important to us. If you
More informationC A L H O U N COUNTY SCHOO LS
C A L H O U N COUNTY SCHOO LS Dear Parent/Guardian: Children need healthy meals to learn. Calhoun County Schools offers healthy meals every school day. Breakfast costs $1.50; lunch costs $1.75. Your children
More informationMILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030
MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT Nutrition Services 777 Garfield Avenue Milford, OH 45150 (513) 831-5030 **NOW AVAILABLE** ONLINE FREE AND REDUCED APPLICATIONS FOR MILFORD EXEMPTED VILLAGE SCHOOLS
More informationTennessee Early Childhood Training Alliance
March 25, 2016 Tennessee Early Childhood Training Alliance 737 Union Avenue, E-105 Memphis, TN 38103 (901) 333-5541 fax: (901) 333-5750 www.southwest.tn.edu\tecta Dear TECTA Scholarship Recipient, I hope
More informationHOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS
HOW TO APPLY FOR FREE AND REDUCED PRICE SCHOOL MEALS Please use these instructions to help you fill out the application for free or reduced price school meals. You only need to submit one application per
More informationName. Address. City, State, Zip County Phone Number Home: Work: SSN Email Date of Birth (mm/dd/yyyy) Gender. Employment Status
Name Address City, State, Zip County Phone Number Home: Work: SSN Email Date of Birth (mm/dd/yyyy) Gender Date: Employment Status Name of Center, FCC or LFCC Address Center, FCC or LFCC Phone Number Center,
More informationStudent Scholarship Application
Student Scholarship Application Take Stock in Children scholarship recipients receive: A Scholarship A full-tuition Florida Prepaid College Scholarship, which can be used at any public university, college,
More informationDate: Employment Status. What is your current job title? Family Based Professional Non-Teaching Professional Staff Non-Teaching Support Staff
T.E.A.C.H. Early Childhood WASHINGTON, DC Associate/Bachelor s Degree Scholarship Program Application Return this application and all supporting documentation to: NBCDI Attn: T.E.A.C.H. 1313 L Street,
More informationAddress: Street City State Zip Code Home Phone: E-mail Address:
SANDWICH CUSD #430 REGISTRATION FORM SCHOOL YEAR 2013-2014 SELECT AN ATTENDANCE CENTER LG Haskin Prairie View WW Woodbury HE Dummer Middle School High School 1. NAME: 5. SEX: Male Female Last Name First
More informationEnrollment Forms Packet (EFP)
Enrollment Forms Packet (EFP) Please review the information below. Based on r student(s) grade and applicable circumstances, are required to submit documentation in order to complete this step in the enrollment
More informationAssociate Degree Scholarship Application Checklist Family Home Provider
Associate Degree Scholarship Application Checklist Family Home Provider Please submit all of the following information with your completed application. Complete application (all sections completed) Copy
More informationMEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN
Si necesita ayuda para llenar el formulario favor de llamar al 1-800-456-8900 Please PRINT in blue or black ink. MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN Date
More informationJump-Start/Final Step Scholarship Application Checklist Teachers and Directors of Centers
Checklist Teachers and Directors of Centers Please submit all of the following information with your completed application. Complete application (all sections completed) Copy of child care center/family
More informationName. Address. City, State, Zip County Phone Number Home: Work: SSN Email Date of Birth (mm/dd/yyyy) Gender. Employment Status
Delaware Association for the Education of Young Children (DAEYC) T.E.A.C.H. Early Childhood Delaware (T.E.A.C.H.) Associate Degree Scholarship Application Name Address City, State, Zip County Phone Number
More informationT.E.A.C.H. Early Childhood VERMONT Associate Degree Family Child Care Provider Scholarship Application
T.E.A.C.H. Early Childhood VERMONT Associate Degree Family Child Care Provider Scholarship Name Phone Number Home: Work: Cell: Email Address City, State, Zip County SSN Date of Birth (mm/dd/yyyy) Gender
More informationECEC Application Revised 01.5.15
Salt River Pima-Maricopa Indian Community Early Childhood Education Programs Mailing Address: 10, 005 E. Osborn Road Physical Address: 4815 N. Center Street Scottsdale, AZ 85256 Phone: 480-362-2200 Fax:
More informationApply for Free and Reduced Price Meals OR Prepay for Meals Online!
Stafford County Public Schools Apply for Free and Reduced Price Meals OR Prepay for Meals Online! Dear Parent/Guardian, Stafford County Public Schools Is pleased to announce the availability of applying
More informationHealth Insurance for Illinois Families. Rod R. Blagojevich, Governor
Health Insurance for Illinois Families Rod R. Blagojevich, Governor KC 2378KC (R-3-04) IL478-2437 KidCare and FamilyCare Plans KidCare and FamilyCare are health insurance plans for Illinois residents.
More informationEARLY CHILDHOOD CARE AND EDUCATION RECRUITMENT/REFERRAL FORM
EARLY CHILDHOOD CARE AND EDUCATION RECRUITMENT/REFERRAL FORM Please return form to: Listed below are several high quality program options for which your child may be eligible. The goal of this form is
More informationAssociate Degree Scholarship Application Checklist
Associate Degree Scholarship Application Checklist Please submit all of the following information with your completed application. Complete application (all sections completed) Copy of child care center/family
More informationBachelor s Degree Scholarship Application Checklist
Bachelor s Degree Scholarship Application Checklist Please submit all of the following information with your completed application. Complete application (all sections completed) Copy of child care center/family
More informationApplication for Vocational Rehabilitation Services
Strong Families Make a Strong Kansas Application for Vocational Rehabilitation Services Is Vocational Rehabilitation the right program for you? Some brief information about the Vocational Rehabilitation
More informationCarroll College Matched Education Savings Account Application
PERSONAL INFORMATION Name: Social Sec. No. (last four digits): Gender: Female Male Date of Birth: / / Ethnicity: African American Caucasian Latino or Hispanic Asian, Pacific Islander Native American Other
More informationInstructions for Completing a Medicare Savings Program (MSP) Application
Instructions for Completing a Medicare Savings Program (MSP) Application The attached Department of Human Services (DHS) Health Services Application is used to apply for Medicare Savings Programs (MSP)
More informationPRACTITIONER REGISTRY APPLICATION
Pract Application Rev 06/23/2014 Page 1 PRACTITIONER REGISTRY APPLICATION The Registry verifies trainers, registers training, and tracks the professional development of both practitioners and trainers.
More informationNOTICE OF DIRECT CERTIFICATION
East Catholic School 2001 Ardmore Blvd. Pittsburgh, PA 15221 Phone: 412/351-5403 Fax: 412/273-9114 www.eastcatholicschool.org Dear Parent/Guardian: Children need healthy meals to learn. East Catholic School
More informationPublic Health Management Corporation. Address: Street City Zip Code. Medical Case Manager /Housing Counselor. Email:
APPLICATION COVER PAGE Agency: Address: Street City Zip Code Medical Case Manager /Housing Counselor Phone: (Print Name) Email: I attest the information and documentation submitted is accurate and verified
More informationApplication for Adults and Children with Long Term Care Needs
State of Alaska Department of Health and Social Services Division of Public Assistance Application for Adults and Children with Long Term Care Needs Please check the services you need: Home and Community-Based
More informationWHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN?
HEALTH CHECK (MEDICAID) NC HEALTH CHOICE FOR CHILDREN APPLICATION Free or Low-Cost Health Coverage This application may also be used by parents, caretakers, pregnant women & other adults to apply for Medicaid.
More informationApplication for Subsidized Child Care
COMMONWEALTH OF PENNSYLVANIA Application for Subsidized Child Care This application may be used by families who want help in paying their child care costs. The Child Care Information Services (CCIS) agency
More informationT.E.A.C.H. Early Childhood TEXAS Associate Degree Scholarship Program Application Early Childhood Education/Child Development
Associate Degree Scholarship Program Early Childhood Education/Child Development Date: Name Address City, State, Zip County Phone Number Home: Work: SSN Email Date of Birth (mm/dd/yyyy) Gender Employment
More informationAPPLICATION FOR CRIME VICTIM COMPENSATION (Please print clearly and complete the entire form)
Maryland Criminal Injuries Compensation Board (CICB) Department of Public Safety and Correctional Services 6776 Reisterstown Rd, Ste. 206 Baltimore, MD 21215 410-585-3010 1-888-679-9347 (fax) 410-764-3815
More informationHUMAN RESOURCES STAFF DIRECTORY
HUMAN RESOURCES STAFF DIRECTORY Dr. Kim Mattox kimattox@gaston.k12.nc.us 704-866-6129 Jeppie Hager jbhager@gaston.k12.nc.us 704-866-6183 Cynthia Howell cdhowell@gaston.k12.nc.us 704-866-6123 Asst. Superintendent
More informationT.E.A.C.H. Early Childhood TEXAS Bachelor Degree Scholarship Program Application Early Childhood/Child Development/ Family and Child Studies
Bachelor Degree Scholarship Early Childhood/Child Development/ Family and Child Studies Date: Name Address City, State, Zip County Phone Number SSN Email Date of Birth Gender Home: (mm/dd/yyyy) Work: Employment
More informationHARTLAND CONSOLIDATED SCHOOLS
HARTLAND CONSOLIDATED SCHOOLS Lisa Archey, Student Nutrition Director 10632 Hibner Rd. Telephone (810) 626 2867 Hartland, MI 48353 Fax (810) 626 2869 FREQUENTLY ASKED QUESTIONS ABOUT FREE AND REDUCED PRICE
More informationMALIK ACADEMY AND AL BUSTAN PRESCHOOL FINANCIAL AID/REDUCED TUITION PROGRAM
MALIK ACADEMY AND AL BUSTAN PRESCHOOL FINANCIAL AID/REDUCED TUITION PROGRAM Dear Parent/Guardian: Sending children to private school can be expensive. In order to make our school affordable to as many
More informationSOMERSET DISASTER RECOVERY APPLICATION FOR BUSINESS ASSISTANCE
SOMERSET DISASTER RECOVERY APPLICATION FOR BUSINESS ASSISTANCE Application # Applicant Name: Co-Applicant Name: Business Name: Business Address: City: Zip Code: Home Phone: Work Phone: Cell Phone: Section
More informationApplication for Medical Assistance for Families with Children
Application for Medical Assistance for Families with Children Who can use this application? Use this application to see what choices you have Apply faster online This application is for families, children,
More informationP E N N S Y L V A N I A
P E N N S Y L V A N I A Application for Payment of Medicare Premiums, Coinsurance and Deductibles If you have a disability and need this form in large print or another format, please call our helpline
More informationEducational Talent Search
Dear Parent(s), Educational Talent Search (ETS) is a project funded by the U. S. Department of Education and is administered by Diablo Valley College (DVC). The purpose of this project is to encourage
More information2013-2014 SPECIAL NOTE COMPLETE ONLY ONE FORM FOR YOUR FAMILY.
2013-2014 SPECIAL NOTE COMPLETE ONLY ONE FORM FOR YOUR FAMILY. 1) List all household members, including all of your children in Hall County Schools, in Part 1 of this application. 2) Follow instructions
More informationOur Mission. Promoting Independence by Providing Car Care
Check List Douglas County Residents Only Our Mission Promoting Independence by Providing Car Care Please Submit the Following: FOR ALL APPLICANTS Fill out application completely and sign Sign the attached
More informationRICE COUNTY ENVIRONMENTAL SERVICES RICE COUNTY SUBSURFACE SEWAGE TREATMENT SYSTEM LOW INCOME FIXUP GRANT PROGRAM
(507) 332-6113 RICE COUNTY ENVIRONMENTAL SERVICES 320 Northwest Third Street Suite 9 Faribault, Minnesota 55021-6145 Toll free from Northfield (507) 645-9576 Toll free from Lonsdale (507) 744-5185 TDD
More informationPREQUALIFICATIONS RESULTS OF THE PREQUALIFICATION ARE UNOFFICIAL AND MAY CHANGE WHEN ALL ESTIMATED INFORMATION IS VERIFIED.
CENTRAL APPALACHIA EMPOWERMENT ZONE OF WEST VIRGINIA P.O. Box 176 Phone: 304/587-2034 Fax: 304/587-2027 PREQUALIFICATIONS The Prequalification process gives the Central Appalachia Empowerment Zone of WV
More informationLouisiana Children s Health Insurance Program (LaCHIP) is no-cost health insurance for children under age 19.
Louisiana Children s Health Insurance Program (LaCHIP) is no-cost health insurance for children under age 19. Ways to Apply Online Apply at www.lachip.org Mail Mail the application and documents of proof
More informationHealth Care Coverage APPLICATION FOR. Health Care in Pennsylvania. Easy, affordable protection for your family
Important information about health care benefits. Ask someone to read this to you. APPLICATION FOR Health Care Coverage This application may be used by families with children or by pregnant women who apply
More informationApplication. For Veterans Care Health Insurance. Veterans Care covers veterans who need health insurance. Other Important Information
Application For Veterans Care Health Insurance There are thousands of veterans in Illinois who are living without health insurance because they can t afford it. The citizens of Illinois feel a sense of
More informationLincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application
Lincoln Memorial University- DeBusk College of Osteopathic Medicine Physician Assistant Program Supplemental Application Date of Application: LMU ID # (if applicable): Name Last First Middle Preferred
More informationCREDIT & BUDGET COUNSELING CHECKLIST. Completed Housing Intake Forms Including Budget Sheet, Release of Information, & Privacy Statement
CREDIT & BUDGET COUNSELING CHECKLIST PLEASE BRING EACH OF THE FOLLOWING TO YOUR APPOINTMENT: Completed Housing Intake Forms Including Budget Sheet, Release of Information, & Privacy Statement Copy of Pay
More informationHealth Benefits for Workers with Disabilities Application
Illinois Department of Public Aid Health Benefits for Workers with Disabilities Application Note: This is NOT an application for cash assistance, food stamps or enrollment in the Medicaid spenddown program.
More informationACCESS NY HEALTH CARE Child Health Plus / Family Health Plus / Medicaid / PCAP / WIC
ACCESS NY HEALTH CARE Child Health Plus / Family Health Plus / Medicaid / PCAP / WIC PLEASE READ the entire application and INSTRUCTIONS before you fill it out. Print clearly in blue or black ink. If you
More informationInformation on Legal Relationships and Public Benefits for Grandparents Raising Grandchildren
Information on Legal Relationships and Public Benefits for Grandparents Raising Grandchildren FROM ATLANTA LEGAL AID SOCIETY S GRANDPARENT/RELATIVE CAREGIVER PROJECT & GEORGIA SENIOR LEGAL HOTLINE Supported
More informationSOMERSET DISASTER RECOVERY APPLICATION FOR HOMEOWNER ASSISTANCE
SOMERSET DISASTER RECOVERY APPLICATION FOR HOMEOWNER ASSISTANCE Application # Applicant Name: Co-Applicant Name: Property Address: City: Zip Code: Home Phone: Work Phone: Cell Phone: Section 1 - Property
More informationY O U T H L E A D. Summer U LEAD Program Application
Summer U LEAD Program Application Y O U T H L E A D U LEAD is sponsoring a summer job program for Ramsey County Suburban youth ages 14 to 24. Youth must complete the summer application and complete work
More informationSample enrollment Checklist for Bullis Charter School
Registration Checklist Open Enrollment Period: November 1, 2011 February 3, 2012 Thank you for registering your child in Bullis Charter School. Enclosed in this packet are the registration materials that
More informationCHILD CARE PROGRAM BUSINESS INFORMATION FORM
CHILD CARE PROGRAM BUSINESS INFORMATION FORM Date Completed: / / Completed By: General Information Name: Title: Business Name: NCFR will release your program name and information to families seeking child
More informationEarly Childhood Rhode Island Scholarship Application
Page 1 of 9 T.E.A.C.H. Early Childhood Rhode Island Scholarship Application Associate s Degree Employed Directors and Owner/Operator Directors AED/AO Models Date: 1. Name: 2. Address: County: City: State:
More informationcan provide you with medical insurance for your entire family
Affordable health coverage. Quality care. can provide you with medical insurance for your entire family You may be able to receive NJ FamilyCare, free or low-cost health insurance for adults and children
More informationInstructions to fill out this Application
Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP offers health care for children, from birth to age 18, whose families
More informationBEAVER DAM UNIFIED SCHOOL DISTRICT NUTRITIONAL SERVICES MANAGED BY TAHER, INC.
BEAVER DAM UNIFIED SCHOOL DISTRICT NUTRITIONAL SERVICES MANAGED BY TAHER, INC. 500 GOULD STREET, BEAVER DAM, WI 53916 PHONE: 920-885-7300 EXT. 2165 EMAIL: TAHER@BDUSD.ORG NOURISHING THE MINDS OF THE FUTURE
More information2014-2015 Enrollment Packet
2014-2015 Enrollment Packet Please review the information below. Based on your student (s) grade and applicable circumstances, you are required to submit documentation in order to complete this step in
More informationT H E U N I V E R S I T Y O F G E O R G I A A P P L I C A T I O N F O R T R A N S F E R A D M I S S I O N PLEASE NOTE: The PDF applications are for review purposes only. Official applications must be submitted
More informationNeighborhood Checkup
Promise Neighborhoods Research Consortium (PNRC) Neighborhood Checkup Survey of Current Supports for Successful Youth Development First, we are going to ask you a few questions about your. For this survey,
More informationDistance Learning Program Application Please complete one application for each student applying for admission.
Division of Accelerated Christian Education Ministries Distance Learning Program Application Please complete one application for each student applying for admission. Student Information Account Information
More informationINSTRUCTIONAL, PROFESSIONAL OR ADMINISTRATIVE STAFF APPLICATION
INSTRUCTIONAL, PROFESSIONAL OR ADMINISTRATIVE STAFF APPLICATION Position for which you are applying Please type or print clearly in ink. Complete all sections even if enclosing a resume. Please submit
More informationTransportation Construction Apprenticeship Readiness Training T.C.A.R.T. Cell Phone Date of Birth (mm/dd/yyyy) Gender: Male
PROGRAM APPLICATION Host CBO: Applicant # Last Name Address Home Phone SS# Email First Name City/State/Zip Cell Phone Date of Birth (mm/dd/yyyy) Middle Initial I have the legal right to work in the US.
More informationApplication & Renewal Form
Section A: I want health insurance for: (Check ( ) the category or categories that match your situation.) Myself, my spouse (or other parent of my children) and our children under age 19 who live with
More informationApplication for Health Coverage & Help Paying Costs
Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health insurance plans that offer
More informationAware, WHERE CAN. You do not have. this as well. the rating level: Up to. child. $5,000 per. $4,000 per. Up to. Up to. $3,000 per HOW.
SUPPLEMENTAL INFORMATION EARLY LEARNING SCHOLARSHIP SUPPLEMENTAL INFORMATION: APPLICATION FOR PATHWAY I - EARLY LEARNING SCHOLARSHIPS WHAT IS AN EARLY LEARNING SCHOLARSHIP? A Pathway I - Early Learning
More informationE. C. GLASS HIGH SCHOOL 2111 MEMORIAL AVENUE, LYNCHBURG, VA 24501
E. C. GLASS HIGH SCHOOL 2111 MEMORIAL AVENUE, LYNCHBURG, VA 24501 COUNSELING DEPARTMENT MAIN OFFICE Janet Reynolds Director Dr. Tracy Richardson, Principal 434-515-5372 / FAX: 434-522-3746 434-515-5370
More information