Head Start or Chesapeake Public Schools Preschool Initiative Application 2020-2021

Program Use Only

Application/Interview Site:

Date:

Child’s Last Name:

First Name:

Middle Name:

Age as of September 30th:

DOB:

Gender:

Primary Language at Home:

Race:

Ethnicity:

Person Completing Application:

Relationship to Child:

Home Address:

City: State: Zip:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

Email Address:

Which school will your child attend for Kindergarten?

Which school would you like your child to attend for CPI?

Emergency Contacts:

Contact 1

Name: Address:

Phone Number: Relationship to Child:

Contact 2

Name: Address:

Phone Number: Relationship to Child:

Special Needs

Does your child have an IEP or Disability?

If yes, is Documentation provided? Yes No

Check all that apply: ADHD LD ED Autism Speech

Other:

If No, do you suspect your child may have special needs or a disability?

Has your child been diagnosed with any serious or chronic health conditions? Asthma, other?

Explain:

Does your child have any medically diagnosed allergies? (food allergies, dust, pollen, other)?

Explain:

Is your child toilet trained?

Children must be toilet trained without the use of diapers or pull-ups prior to entering CPI .

Parent/Guardian Living in the same household as the Applicant

Parent/Guardian

Adult 1

Male Female

Date of Birth:

Relationship to Child:

Check all that apply:

Employed: *Note - hold the CTRL key down and click to select multiple options. Please complete.

This section is required.

Adult 2

Male Female

Date of Birth:

Relationship to Child:

Check all that apply:

Employed: *Note hold the CTRL key down and click to select multiple options. Please complete.

This section is required.

Family Members Living in the Household Supported by Parent/Guardian Income (Include the Applicant and All Other Siblings)

Name 1

Male Female Date of Birth: Relationship to Applicant:

Name 2

Male Female Date of Birth: Relationship to Applicant:

Name 3

Male Female Date of Birth: Relationship to Applicant:

Name 4

Male Female Date of Birth: Relationship to Applicant:

Name 5

Male Female Date of Birth: Relationship to Applicant:

Name 6

Male Female Date of Birth: Relationship to Applicant:

Total Number in Family:

Other Household Members

Name 1

Male Female Date of Birth: Relationship to Applicant:

Name 2

Male Female Date of Birth: Relationship to Applicant:

Name 3

Male Female Date of Birth: Relationship to Applicant:

Name 4

Male Female Date of Birth: Relationship to Applicant:

Total Number in Household:

Family Type:

Marital Status:

Court Custody Information:

Please Check All of the Following Situations That Apply to Your Family. Please complete.

This section is required.

Child’s Health Insurance:

None Private Medicaid FAMIS Other

Mother’s Health Insurance:

None Private Medicaid FAMIS Other

Father’s Health Insurance:

None Private Medicaid Other

Child previously/currently enrolled in Head Start/Preschool/Daycare? Where:

Referred by a professional agency? Which Agency?

Did parent(s) graduate from high school?

Mother: If No, did she obtain GED?

Father: If No, did he obtain GED?

Did parent(s) attend and complete college?

Mother: If Yes, Degree:

Father: If Yes, Degree:

Parent(s) are currently in: School Job Training

Limited English Proficiency: Family: Child:

Lack of family support in the area?

Active Duty Military? If Yes, Deployment history/dates?

Residing in Section 8/Public Housing (government assisted)?

Are you lacking fixed, regular, adequate housing, or are you homeless at this time?

Yes, please go to the Chesapeake Public schools Office if Student Enrollment, Attendance and Residency for residence approval.

Living with relatives or others due to:

Recent change in family structure/guardianship within one year?

Domestic violence/traumas witnessed or encountered by child? Please explain:

Physical abuse/sexual abuse of child? Please explain:

Recent death/suicide of a relative that would impact the child?

Relationship to child:

Teenage parent (under 18)?

Age of parents at birth of first child: Mother: Father:

First child’s birth date:

Disabled parent or family member within household?

Relationship to child:

Serious health concern of a family member(s) within the household?

Relationship to child:

Condition(s):

Any family member within the household receiving counseling services? Please explain.

Substance Abuse (parent)? Please explain.

Incarcerated parent in the past or currently. Please explain: (reason, place, and time)

Self-Reported Family Income from All Sources:

WIC Number:

SNAP Number:

TANF Number:

TANF Monthly Amount:

Family Member 1

Income Source-Job/SSI/Child Support:

Amount:

Frequency:

Yearly Amount:

Documents Provided:

Family Member 2

Income Source-Job/SSI/Child Support:

Amount:

Frequency:

Yearly Amount:

Documents Provided:

Please check the box below and provide your initials, signature, and date.

By submitting this application, I give my permission for my child to be considered and accepted into Head Start and/or Chesapeake Preschool Initiative (CPI). I further understand placement will be determined by the Head Start and/or the CPI Eligibility Committee.

Parent/Guardian Signature: Date:

CPI Staff Signature: Date:

Head Start Staff Signature: Date:

Certification: I certify that all of the information on this application is true. If any part is false,

participation in either program may be terminated and I may be subject to legal action. I understand

that the information in this application will be held in strict confidence, and is accessible to me during

normal business hours. I also understand that this I not a first-come, first served process, and that

selection is based on weighted risk factors. Children with the highest risk factors will be selected first.

In conclusion, I understand that program eligibility is conditional on being a resident of

Chesapeake and regular program attendance.

Please complete this form, and print a hard copy to bring with you to your eligibility screening appointment. To ensure that you do not have to complete this application twice, please save it electronically for your records.

Please do not email this application or documents containing sensitive personally identifiable information. Instead, bring the application and all related documents with you, at the time of your eligibility screening appointment, to the Instructional Services Center, 304 Cedar Road, Chesapeake, VA 23322.

Head Start or Chesapeake Public Schools Preschool Initiative Application

Below are steps that must be completed before a child may be officially enrolled in Head Start or the

Chesapeake Preschool Initiative (CPI).

Step 1 Chesapeake Preschool Initiative (CPI): Schedule an eligibility screening appointment by

calling

(757) 842-4099. The appointment window typically opens the last week of February.

Head Start: Schedule an eligibility screening appointment by calling (757) 673-0548.

The appointment window typically opens in late February.

Step 2

The parent/legal guardian must complete All parts of the application, and must provide All required

documents prior to the eligibility screening.

Required Documents:

Child’s original certified birth certificate or birth certificate affidavit. Parent/Legal Guardian Identification Proof of residence: an electric, gas, or water bill in your name showing usage in the last 30 days

or a CPS approved Special Enrollment Detail Report from the Office of Student Enrollment, Attendance, and Residency.

Proof of income: W2 (previous year), SSA, 1099, SSI, or two most recent pay stubs for all employed parent/guardian(s) in the household.

Unemployment, worker’s compensation payments, veteran’s benefits, survivor benefit payments, retirement, interest and dividends, rents and royalties, income from estates and trusts, income from educational assistance, financial assistance from outside household are considered income and must be included. Unemployment income determination letter (if applicable)

SNAP and/or TANF documentation, and case number(s) (if applicable) WIC ID number (if applicable) Court Custody documents (if applicable) Court Child Support documents (if applicable) Current phone numbers and addresses for two (2) emergency contacts

Parents are strongly encouraged to call (757) 842-4099 beginning the last week of February to schedule a screening appointment in order to be considered for placement in June.

Step 3

CPI selection and notification takes place each June. A notification letter will be mailed the first week

of June, and will include additional information needed to complete all the requirements and enrollment

procedures listed in Step 4.

Head Start notification letters will be mailed the first week of May.

Step 4

When a child is accepted into the CPI program, the parent/legal guardian must complete the last portion

of the enrollment packet and submit it to the appropriate CPI location by July 16, 2020. Parent/legal

guardians are also required to attend a mandatory program orientation in August.

When a child is accepted into the Head Start program, the parent/guardian will be contacted by a Case

Manager to schedule an appointment to complete the enrollment packet.

If you have any questions or concerns, please contact the following:

Chesapeake Preschool Initiative Head Start

Ashley Nolette, CPI Coordinator Tonya Murphy, Family Community Engagement Coordinator

(757) 842-4099 (757) 673-0548

Ashley.Nolette@cpschools.com Tonyamurphy@hrcapinc.org

Mickey Jennings, CPI Secretary Kenya Moore, Family Services Manager

(757) 842-4099 (757) 673-0548

Mickey.Jennings@cpschools.com Kenya.Moore@hrcapinc.org

mailto:Kenya.Moore@hrcapinc.orgmailto:Mickey.Jennings@cpschools.com

Head Start Preschool Programs

Application and Eligibility Screenings

Three and Four-Year-Old Programs

(757) 673-0548

Head Start will complete eligibility screening appointments for children who are three or four-years old.

Parents interested in applying should call (757) 673-0548 to schedule an eligibility screening

appointment.

Registration begins mid-February. Applications and instructions may be picked up from any CPS primary or elementary school, the Instructional Services Center, 304 Cedar Road, or from the CPS website (www.cpschools.com) beginning the last week of February.

Applying does not guarantee placement. Head Start children must be 3 or 4 years old by September 30th .

Students Are Not Selected On a First Come-First Served Basis

Chesapeake Public Schools Preschool Initiative

Application and Eligibility Screenings

Four-Year-Old Program Only

Instructional Services Center

304 Cedar Road, Chesapeake, VA 23322

(757) 842-4099

CPI will conduct eligibility screenings beginning in March. Parents must have all the necessary

paperwork and a completed application before the screening appointment can be scheduled.

Applications and instructions may be picked up from any CPS primary or elementary school, the

Instructional Services Center, 304 Cedar Road, or from the CPS website (www.cpschools.com)

beginning the last week of February.

Program eligibility is conditional on being a resident of Chesapeake and regular program attendance.

Applying does not guarantee program placement. Incomplete packets cannot be accepted. Chesapeake Preschool Initiative children must be 4 years old by September 30th.

http:www.cpschools.comhttp:www.cpschools.com

CPI Locations

B. M. Williams Primary School Southwestern Elementary School

Camelot Elementary School Thurgood Marshall Elementary School

Georgetown Primary School Western Branch Primary School

Rena B. Wright primary School

Application Instructions

Applications and instructions may be picked up from any CPS primary or elementary school, the

Instructional Services Center, 304 Cedar Road, or from the CPS website (www.cpschools.com)

beginning the last week of February.

Required Documents

Parent(s)/Legal Guardian(s) must provide the following information before the application can be

accepted.

Child’s original birth certificate or birth certificate affidavit

Parent/Legal Guardian Identification

Proof of residence: an electric, gas, or water bill in your name showing usage within the last 30

days or a Special Enrollment Detail report from the Office of Student Enrollment, Attendance

and Residency.

Proof of income – W2 (previous year), SSA, 1099, SSI, or two most recent pay stubs, for all

parent/guardian(s) living in the household. Unemployment, worker’s compensation payments,

veteran’s benefits, survivor benefit payments, retirement, interest and dividends, rents and

royalties, income from estates and trusts, income from educational assistance, financial

assistance from outside the household are considered income and must be included.

Unemployment income determination letter (if applicable)

SNAP and/or TANF documentation and case number (if applicable)

WIC ID number (if applicable)

Court Custody documents (if applicable)

Court Child Support documents (if applicable)

Current phone numbers and addresses for two (2) emergency contacts

http:www.cpschools.com

Gender: [ ]Primary Language: [ ]Application Interview Site: Application Date: Childs Last Name: Childs First Name: Child's Middle Name: Age September 30: DOB: Race: [ ]Ethnicity: [ ]Person Completing Application: Relationship to Child: Home Address: City: State: Zip: Home Phone Number: Work Phone Number: Cell Phone Number: Email Address: Kinidergarten Choice: CPI Choice: Contact 1 Name: Contact 1 Address: Contact 1 Phone Number: Contact 1 Relationaship to Child: Contact 2 Name: Contact 2 Address: Contact 2 Phone Number: Contact 2 Relationship to Child: IEP or Disability: [ ]Yes Documentation: OffNo Documentation: OffADHD: OffLD: OffED: OffAutism: OffSpeech: OffOther: Suspect Disability: [ ]Disgnosed with Serious or Chronic Condition: [ ]Explaination for Cronic Health Condition: Diagnosed Allergies: [ ]Explaintion for Diagnosed Allergies: Toilet Trained: [ ]Parent Guardian Adult 1: Male Parent Guardian Adult 1: OffFemale Parent Guardian Adult 1: OffParent Guardian Adult 1 DOB: Parent Guardian Adult 1 Relationship to child: Adult 2 Employment: [ ]Adult 1 Employment: [ ]Parent Guardian Adult 2: Male Parent Guardian Adult 2: OffFemale Parent Guardian Adult 2: OffParent Guardian Adult 2 DOB: Parent Guardian Adult 2 Relationship to Child: FMLH Name 1: Male FMLH Name 1: OffFemale FMLH Name 1: OffDOB FMLH Name 1: Relationship FMLH Name 1: FMLH Name 2: Male FMLH Name 2: OffFemale FMLH Name 2: OffDOB FMLH Name 2: Relationship FMLH Name 2: FMLH Name 3: Male FMLH Name 3: OffFemale FMLH Name 3: OffDOB FMLH Name 3: Relationship FMLH Name 3: FMLH Name 4: Male FMLH Name 4: OffFemale FMLH Name 4: OffRelationship FMLH Name 4: FMLH Name 5: Male FMLH Name 5: OffFemale FMLH Name 5: OffDOB FMLH Name 4: DOB FMLH Name 5: Relationship FMLH Name 5: FMLH Name 6: Male FMLH Name 6: OffFemale FMLH Name 6: OffDOB FMLH Name 6: Relationship FMLH Name 6: Total Number in Family FMLH: Other Household Members Name 1: Male Other Household Members Name 1: OffFemale Other Household Members Name 1: OffDOB Other Household Members Name 1: Relationship Other Household Members Name 1: Other Household Members Name 2: Male Other Household Members Name 2: OffFemale Other Household Members Name 2: OffDOB Other Household Members Name 2: Relationship Other Household Members Name 2: Other Household Members Name 3: Male Other Household Members Name 3: OffFemale Other Household Members Name 3: OffDOB Other Household Members Name 3: Relationship Other Household Members Name 3: Other Household Members Name 4: Male Other Household Members Name 4: OffFemale Other Household Members Name 4: OffDOB Other Household Members Name 4: Relationship Other Household Members Name 4: Total Number in Household Other Household Members: Family Type Other Household Members: [ ]Marital Status Other Household Members: [ ]Court Custody Information Other Household Members: [ ]CHI None: OffCHI Private: OffCHI Medicaid: OffCHI FAMIS: OffCHI Other: OffMother None: OffMother Private: OffMother Medicaid: OffMother FAMIS: OffMother Other: OffFather None: OffFather Private: OffFather Medicaid: OffFather Other: OffExplain Child Previouosl Enrolled: Explain Referred by Professional Agency: Did Mother Graduate High School: []Did Father Graduate High School: []Did Mother Obtain GED: []Did Father Obtain GED: []Father Attended and Completed College: []Mother Attended and Completed College: []Yes Mother Degree Earned: Yes Father Degree Earned: Parents Currently In School: OffParents Currently In Job Training: OffLimited English Proficiency: OffFamily Limited English Proficiency: []Child Limited English Proficiency: []Lack Family Support in Area: OffActive Military Duty: [ ]Deployment History and Dates: Did Parents Graduate from High School: [ ]Child Previousl Enrolled in HS or Preschool: []Referred by Professional Agency: [ ]Did Parents Attend and Complete College: [ ]Residing Section 8 Public Housing: [ ]Lacking Adequite Houseing or Homeless: [ ]Living with Relatives or Others: [ ]Explaination Living with Relatives or Others: Recent Family Structure Changes: [ ]Explaination for Recent Family Structure Changes: Domestic Violence or Trauma: [ ]Explaination for Domestic Violence or Trauma: Physical or Sexual Abuse: [ ]Explaination for Physical or Sexual Abuse: Recent Death Suicide of Relative: [ ]Recent Death Suicide of Relative's Relationship to Child: Teenage Parent Under 18: [ ]Mother Age Birth First Child: Fathers Age Birth First Child: First Child Birth Date: Disabled Family Member in Household: [ ]Disabled Family Member in Household Relationship to Child: Serious Helath of Family Member in Household: [ ]Serious Helath of Family Member in Household Relationship to Child: Conditions: Counseling Servives for Members of Household: [ ]Explaination for Counseling Servives for Members of Household: Substance Abuse Parent: [ ]Explaination for Substance Abuse Parent: Incarcerated Parent Past or Present: [ ]Explaination for Incarcerated Parent Past or Present: WIC Number: SNAP Number: TANF Number: TANF Monthly Amount: Income Family Member 1: Income Sources Family Member 1: Amount Family Member 1: Frequency Family Member 1: Yearly Amount Family Member 1: Documents Provided Family Member 1: Income Family Member 2: Income Sources Family Member 2: Amount Family Member 2: Frequency Family Member 2: Yearly Amount Family Member 2: Documents Provided Family Member 2: Permission Granted: OffInitials: Date Parent Guardisn Signation for Permission: Date CPI Staff Signature for Receipt: Date Head Start Staff Signature for Receipt: Childs Birth Certificate: OffParent Legal Guardian ID: OffProof of Residence: OffProof of Income: OffUnemployment Determination Letter: OffSNAP and/or TANF Documentation: OffWIC ID Number if Applicable: OffCourt Custody Documents: OffCourt Child Support Documents: Off2 Current Phone Numbers and Addresses: Off