2018-2019 Onslow County Preschool Applications ...

1 Head Start The Head Start program is a federally funded educational, health, and social program designed to work with families who are economically disadvantaged. The students served are 3 or 4 years old on or before August 31st. All students selected for the Head Start program must live in the Onslow County Schools district attendance area. Eligibility is determined using Federal income guidelines. Onslow County Schools Preschool Office, Thompson Early Childhood Center 440 College St, Jacksonville Applications accepted Monday Thursday 9:00-3:00 For more information contact 910-455-5530 or visit Onslow County Partnership for Children Resource Center 101 North Plain Rd , Jacksonville Applications accepted M, Tu, Th, F from 9:00-4:00 For more information contact 910-938-0336 or visit Onslow County Preschool Programs Program Birth Certificate Child's Immunization Record *Proof of Residence Proof of Identity State ID.

2 Driver s License, Military ID Foster Care/Kinship Care Documentation If Applicable Proof of Enrollment School Schedule Enrollment Letter If Applicable Special Needs Documentation IEP/IFSP Chronic Health Plan Therapy Plan of Care If Applicable Proof of Military Affiliation** LES or DEERS Registration DD214 VA Disability Letter If Applicable All Sources of Income Requirements are based on program. Please refer to each individual program. You may be required to submit additional documents to determine eligibility. Head Start Required Required Required *Notarized Required Required N/A If Applicable If Applicable Last 12 months of family income: 2017 Tax Return, and last pay stubs for 2018 If Applicable: SSI/WFFA/TANF (statements), Alimony, Retirement, Unemployment, Disa-bility, VA Benefits (pension, compensation, etc.)

3 , Child Support verification of ALL CHILDREN in the home or verification of no child support. Title 1 Required Required Required *Notarized Required Required N/A If Applicable If Applicable Last 12 months of family income: 2017 Tax Return, and last pay stubs for 2018 If Applicable: SSI/WFFA/TANF (statements), Alimony, Retirement, Unemployment, Disa-bility, VA Benefits (pension, compensation, etc.), Child Support verification of ALL CHILDREN in the home or verification of no child support. NC Pre-K Required Required Required Required Required N/A If Applicable **Required If Applicable Four (4) consecutive weekly current paystubs (or 2 semi-monthly/bi-weekly paystubs) or 2017 Tax Return or all 2017 W2s If Applicable: SSI/WFFA/TANF (statements), Alimony, Retirement, Unemployment, Disa-bility, VA Benefits (pension, compensation, etc.)

4 , Child Support. Three School Required Required Required Required Required Required If Applicable If Applicable Four (4) consecutive weekly current paystubs (or 2 semi-monthly/bi-weekly paystubs) *parent(s)/guardian(s) must be working or going to school If Applicable: SSI/WFFA/TANF (statements), Alimony, Retirement, Unemployment, Disa-bility, VA Benefits (pension, compensation, etc.), Child Support. *Current Utility Bill (water/power) *If parent or guardian name is not on bill; bill and (*notarized) signed letter from payee stating that family is residing at the residence is needed Title 1 The Title I program is a federally funded educational program. The students served must be 4 years old on or before August 31st. Each child is administered a developmental screening assessment to determine his/her educational need.

5 All students selected for the Title I program must live in Onslow NC Pre-Kindergarten The NC Pre-K Program is a state program designed to provide high-quality educational experiences to enhance school readiness. The NC Pre-K Program believes that to be successful academically in school, children need to be prepared in all five of the developmental domains that are critical to children s overall well-being and success in reading and math as they enter school: Approaches to play and learning: Emo-tional and Social Development, Health and Physical Development, Language Development and Communi-cation, and Cognitive Development. Children that are 4 by August 31, 2018 are encouraged to apply. Smart Start Onslow Three School Three School is a locally designed program to provide high-quality educational experiences to enhance school readiness to children who may not be otherwise served.

6 Children that are 3 by August 31, 2018 , meet TANF income eligibility, and parents are working or going to school are encouraged to apply. 2018 - 2019 Onslow County Preschool Applications Applications Accepted at the following locations: 2018 - 2019 Preschool Income Guidelines Table 1. NC Pre-K Income Eligibility Family Size Monthly Income Limit Annual Income 1 $2, $27, 2 $2, $35, 3 $3, $44, 4 $4, $52, 5 $5, $60, 6 $5, $69, 7 $5, $70, 8 $6, $72, Table 2. Three School Income Eligibility Family Size Monthly Income Limit Annual Income Limit 1 $2, $24, 2 $2, $32, 3 $3, $40, 4 $4, $49, 5 $4, $57, 6 $5, $65, 7 $6, $74, 8 $6, $82, 1 Head Start Onslow County Preschool Application 2018 - 2019 This application serves as an application for Onslow County Preschools and Onslow County Partnership for Children CHILD INFORMATION Child s Le gal N ame: _____ First Middle Last Child s Prefer red N ame: _____ Birthdate: / / Age: (As of 8/31/ 2018 ) 3 4 Gender: Male Female Physical Address.

7 , NC Street City Zip code County Mailing Address: , NC *if different from above Street/PO Box City Zip code County Race: Black White Multi-Racial Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Other: Hispanic: Yes No English Proficiency: None Little Moderate Proficient Other Language: Other Language Proficiency: None Little Moderate Proficient Primary Health Coverage: Medicaid NC Health Choice Private Insurance Other No Insurance Who does the child reside with? Both Parents/Step-Parent Mother Father Legal Guardian/Foster Parent(s) Grandparent(s) Other: (Explain) PARENT/GUARDIAN PRIMARY Parent /Guardian Name: Birthdate: / / Gender: Male Female Physical Address: , NC *if different from child Street City Zip code County Mailing Address: , NC *if different from above Street/PO Box City Zip code County Phone number #1: ( ) - Phone number #2: ( ) - Cell Home Work Other: Cell Home Work Other: Opt in for text messages: Yes No Email: Marital Status: Single Married Separated Divorced Widowed Custody: Yes No Race: Black White Multi-Racial Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Other: Hispanic.

8 Yes No English Proficiency: None Little Moderate Proficient Other Language: Other Language Proficiency: None Little Moderate Proficient Highest Grade Completed: < 9 10 11 GED HS Graduate College or Advanced Training Associate s Bachelor s Master s Doctorate s Enrolled in High School or GED Program Enrolled in Job Training Enrolled in college Employment Status: Full Time Part Time Seasonal Self-Employed Place of Employment: Seeking employment Training or School Disabled Unemployed Retired If unemployed or retired (effective date) /_ Health Coverage: Yes No Provider: Child s name: 2 PARENT/GUARDIAN SECONDARY Parent /Guardian Name: Birthdate: / / Gender: Male Female Physical Address: , NC *if different from child Street City Zip code County Mailing Address: , NC *if different from above Street/PO Box City Zip code County Phone number #1: ( ) - Phone number #2: ( ) - Cell Home Work Other: Cell Home Work Other: Opt in for text messages: Yes No Email: Marital Status: Single Married Separated Divorced Widowed Custody: Yes No Race: Black White Multi-Racial Asian American Indian or Alaskan Native Native Hawaiian or Pacific Islander Other: Hispanic: Yes No English Proficiency: None Little Moderate Proficient Other Language: Other Language Proficiency: None Little Moderate Proficient Highest Grade Completed.

9 < 9 10 11 GED HS Graduate College or Advanced Training Associate s Bachelor s Master s Doctorate s Enrolled in High School or GED Program Enrolled in Job Training Enrolled in college Employment Status: Employment Status: Full Time Part Time Seasonal Self-Employed Place of Employment: Seeking employment Training or School Disabled Unemployed Retired If unemployed or retired (effective date) /_ Health Coverage: Yes No Provider: OTHER HOUSEHOLD MEMBERS First Last Relationship to Child Date of Birth Gender (circle) Female / Male Female / Male Female / Male Female / Male Female/ Male Female/ Male EMERGENCY CONTACTS Emergency Contacts: (Other than Parents) Name: Name: Relationship to Child: Relationship to Child: Phone number: (_ ) - Phone number: (_ ) - Name: Name: Relationship to Child: Relationship to Child: Phone number: (_ ) - Phone number: (_ ) - FAMILY STATUS Parental Status: One Parent household Two Parent household Primary Language at home: English Spanish Other: Check all that apply: Homeless Family Referred by Child/Welfare Agency Receiving Food Stamps (SNAP) WIC MILITARY STATUS Is at least one parent or legal guardian of the applicant an active duty member of the Armed Forces of the US, NC National Guard or other state military force who has served in the last 18 months or expected to be ordered in the next 18 months?

10 Was at least one parent or legal guardian of the applicant killed or seriously injured while serving in the Armed Forces of the US? Yes, Active Duty Yes, Seriously Injured or Killed No Military Veteran Branch: Dates of Active Duty: / / Separated or Retired and Date: / / Child s name: 3 FAMILY/CHILD RISK FACTORS If there are any risk factors below that you are experiencing in your family; please submit documentation along with your application. Mark all that apply Abuse/Neglect Substance Addiction/Abuse Physical/Mental Disability Mental Illness/PTSD Terminal/Chronic Illness Child/Family Trauma (due to deployment, family tragedy, other family issues, or displaced due to political turmoil or natural disaster) Teen Parent 19 or under Guardian 62 or over Incarcerated Parent Death of a Parent/Guardian Other traumatic injuries (please explain) Family lacks a fixed regular and adequate nighttime residence This may include sharing the housing of other persons due to loss of housing, economic hardship or similar reason; living in hotels, motels or camping grounds; living in emergency or transitional shelters; or awaiting foster care placement.