Gaston County Schools Pre-Kindergarten Program APPLICATION

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Cameron Dickerson
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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 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 and indicate whose number (i.e.,. Mom, Dad, etc.) 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 T INCLUDE GRANDPARENTS, FIANCES, AUNTS/UNCLES, ETC.) Names and ages of brothers/sisters: 1

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

2 Mother/Stepmother/Guardian s Name: First Name (please provide even if not in the home) Last Name Mother/stepmother/guardian employed? YES Average hours worked per week: IF T 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 Mother/Stepmother/Guardian Education Level: Less than High School High School Diploma/GED College Father/Stepfather/Guardian s Name: First Name Last Name (please provide even if not in the home) Father/stepfather/guardian employed? YES Average hours worked per week: IF T 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 Father/Stepfather/Guardian Education Level: Less than High School High School Diploma/GED College 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 self-employed, 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 verifiable countable income. Mother/Stepmother/Guardian Signature Father/Stepfather/Guardian Signature 2

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

3 INFORMATION ABOUT YOUR CHILD: 1. The primary language spoken in our home is: English Spanish Other (circle one) 2. Does your child have any identified, chronic health problem(s) diagnosed by a health care provider that may affect his/her school attendance? (circle one) YES List health problem(s) and be prepared to provide documentation from the child s doctor. 3. My child has a current IEP (Individualized Education Program). YES Identified disabilities Special services/therapies received Where does 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 5. Has your child ever been in daycare/childcare? YES Does your child go to daycare/ childcare W? YES Name of daycare/childcare center City, State Do you currently receive daycare vouchers? YES 6. Does your child have any known allergies? YES What are these allergies? 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 T 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 Name of Child s Dentist Office Phone Office Phone Hospital Preference: Caromont Regional Medical Center Telephone: Other Hospital Preference Telephone: 3

(circle one) YES List health problem(s) and be prepared to provide documentation from the child s doctor. 3. My child has a current IEP (Individualized Education Program).

4 My child has: circle one MEDICAID HEALTH INSURANCE Private Health Insurance: Carrier Policy # 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: Do you need school bus transportation? (circle one) YES (This may limit your choices for pre-k) 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 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

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

5 Gaston County NCPK Program has pre-k classrooms located at the following sites. All sites are FREE for the pre-k part of the day, 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). Pre-k locations may change due to space issues. We will make every effort to notify you if this occurs. Income is considered for eligibility and placement at sites marked with asterisks (**). Children may ride the school bus ONLY if you live in the school attendance district. You will be required to provide transportation for your child to any pre-k location outside of your school 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 Bess Elementary Bessemer City Primary Brookside Elementary** Carr Elementary Catawba Heights Elementary** Chapel Grove Elementary** Cherryville Elementary** Costner Elementary** Gardner Park Elementary Lingerfeldt Elementary North Belmont Elementary Page Primary School Pinewood Elementary** Rankin Elementary** Robinson Elementary** Sadler Elementary Springfield Elementary** Tryon Elementary** Woodhill Elementary Bessemer City North New Hope Road area Dallas North Belmont area Chapel Grove area-s. Cherryville Dallas-Cherryville area South area Belmont Abbey area Belmont Mt. Holly Mt. Holly West Stanley Bessemer City-Cherryville area 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

We will make every effort to notify you if this occurs. Income is considered for eligibility and placement at sites marked with asterisks (**).

Gaston County Schools Pre-Kindergarten Program 2015-2016 APPLICATION

Gaston County Schools Pre-Kindergarten Program 2015-2016 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?