Preschool Application (ADA Compliant)

NASH/EDGECOMBE PRE-K APPLICATION FORM
To participate in these pre-kindergarten programs your child must be four years old on or before August 31st of the current program year and must meet one or more of the following requirements:

  • Family’s gross income is at or below 75% of the State Median Income level

  • Child has an identified developmental disability

  • Child has Limited English Proficiency (LEP) as indicated by the family and/or child speaking limited or no English in the home

  • Child has an educational need as indicated by the child’s performance results on an approved developmental screening or in an existing Individualized Education Plan (IEP)

  • Child has a chronic health condition as indicated by the diagnosis from a professional health care provider

  • Child and family are identified as homeless

  • Child is a member of an eligible military family

    **Determination of eligibility does not guarantee a placement in a pre-k program. Placement is also determined by availability of funds**

Please complete the FULL application and include the following attachments:

  • Certified Birth Certificate

  • 30 consecutive days of paystubs for the child’s parents/guardians or a completed wage form signed by the employer (pay information must be no more than two months prior to the date on the application)

  • Copy of most recent health assessment/well-child visit report

  • Written documentation of any other sources of income: Social Security (SSA), SSI Disability, Child Support, etc.

  • Copy of current immunization record

     

Proof of Residency: Provide two (2) proofs of residency

  • Do you own a home? Provide copy of deed, a mortgage statement, or HUD closing statement.

  • Do you rent? Provide copy of rental agreement.

  • Do you live in someone else’s home? Provide a notarized residency affidavit AND their mortgage statement, deed, or lease.

  • ONE of the following items is also required:

    • A gas, water, electric, telephone, OR cable utility bill.

    • A valid North Carolina driver’s license OR identification card.

    • Pay stub, bank statement OR credit card statement dated within the past 30 days.

    • Current vehicle registration, vehicle tax bill, property tax bill, W-2 OR Medicaid card dated within past year.

  • OR Copy of one of the following items: Letter from an approved agency; Refugee resettlement letter; Copy of Housing Authority lease; OR Letter/Statement from hotel/motel if possible.

     

Pre-K is available in a variety of settings in Nash and Edgecombe counties, including private child care centers, Head Start, and public schools. A list of Pre-K providers for the current school year is on our website at www.depc.org or may be included for your convenience – Review the provider list and select your first, second, and third site choices. If you need help choosing a provider contact Family First at (252) 985-4300 ext. 220.

1st Choice:                 2nd Choice:                  3rd Choice:            

Child’s Name:________________________________________Date Processed:____________________________

Processed by: _________________________________________ 

DATE RECEIVED

***CONTRACT ADMINISTRATOR USE ONLY***
PARENT/GUARDIAN INFORMATION

FIRST PARENT/GUARDIAN – Child must be living in the same household as the person(s) listed below.

Parent/Guardian Name:
Relationship to Child:  Mother  Father  Grandparent  Guardian/Custodian  Other:         

Home Address:      
(Please include zip)

Mailing Address:
(If different than home – Please include zip)  

County You Live In: Nash  Edgecombe
Other:
Phone Number: 
Second Phone Number:
Email address:         

Ethnicity: Are you of Latino/Hispanic descent?  Yes  No

Race:  White  Black  Asian  Pacific Islander (please check all  Native American/Alaskan  Middle Eastern that apply)  Other      

Marital Status:  Single  Married  Separated Divorced  Widowed

** If you are employed you must provide

Employment/School Status:  Employed/Self-Employed**  Unemployed 30 days of pay stubs or have your employer complete the attached wage (please check all that apply)
  Seeking Employment  Attending Job Training form.
Attending High School/GED  Attending College 

**Self-employed individuals may submit

Paycheck Received:  Weekly  Bi-Weekly  Semi- Monthly  Monthly W-2 tax form from previous year.

Is there another parent or guardian that lives in the home with the child?  YES  NO

**If there is not a second parent in the home you must mark “NO” to avoid having an incomplete application**

SECOND PARENT/GUARDIAN - You must complete information for each parent in the household.

Parent/Guardian Name:            
Relationship to Child:  Mother  Father  Grandparent  Guardian/Custodian  Other:         
Ethnicity: Are you of Latino/Hispanic descent?  Yes  No
Race:  White  Black  Asian  Pacific Islander (please check all  Native American/Alaskan  Middle Eastern that apply)  Other      
Marital Status:  Single  Married  Separated Divorced  Widowed

** If you are employed you must provide

Employment/School Status:  Employed/Self-Employed**  Unemployed 30 days of pay stubs or have your employer complete the attached wage (please check all that apply)
 Seeking Employment  Attending Job Training form.
 Attending High School/GED  Attending College

**Self-employed individuals may submit

Paycheck Received:  Weekly  Bi-Weekly  Semi- Monthly  Monthly W-2 tax form from previous year.

Does this child have a parent/guardian who was ordered to active duty in the past 18 months or expected to be ordered within

the next 18 months or injured and/or is receiving military disability retirement or was killed while serving on active military duty? Yes No

Does this child have a parent/guardian who is an active duty member of the military? Yes No

PARENT/GUARDIAN MILITARY STATUS

 

CHILD #1

CHILD INFORMATION
Please complete information for each child that needs Pre-K services.

Child’s Full Name:
(as on birth certificate)
Child’s Date of Birth:
Is child of Latino/Hispanic descent? Yes No
Ethnicity:
Gender:
Child’s Race: White Black Asian Pacific Islander
(please check all Native American/Alaskan Middle Eastern that apply) Other      
Who does the child live with?
Family Status: Mother Father Mother & Father
(check one only) Legal Guardian/Custodian
Other:         

CHILD CARE INFORMATION

Who cares for child if you work or go to school?

Enrolled in a child care facility (center or home) Name of facility:             

Previously/no longer enrolled in a child care facility Child cared for by friend, neighbor, or family member Parent stays home with child
Do you receive assistance paying for your child care? 

Receiving assistance with child care from: DEPC Scholarship Program Department of Social Services NEED/Head Start

Other:          

Not receiving assistance with child care (I pay full cost)

SPECIAL NEEDS AND SERVICES 

Does your child have a developmental or educational challenge? Yes No Don’t know

If yes, please explain and attach appropriate documentation:              

Does your child have a physical challenge or chronic illness? YES NO

If yes, please explain and attach appropriate documentation:              

Does your child have an Individualized Education Plan (IEP)? YES NO Don’t know

ADDITIONAL INCOME INFORMATION

Veteran’s Benefits: $     per month Social Security (SSA): $       per month SSI Disability: $       per month
Child Support: $       per month

Unemployment Benefits: $    per month Workers’ Compensation: $      per month
Other:         $       per month
Other:         $       per month

List the amounts of the following income sources that you receive - write in $0 if none is received.
**You must provide written documentation for all additional income sources**|
Statement of “NO INCOME”

To determine eligibility for Nash/Edgecombe pre-kindergarten services it is necessary for you to provide proof of income.
Complete this “No Income” section if you currently have “zero” income.
I  , certify as the parent/legal caregiver(s) of  , have zero income at the time of application. I certify that the above information is true and correct and accurately reported.

Parent/Legal Caregiver Signature
Today’s Date

HOUSEHOLD INFORMATION

**Please list EVERY person living at the home address reported on this application, including the child**

Name
Date of Birth
Relationship to Child

Example: Jane Smith
01/01/1988
Mother

Total number of family members in the home (including child):     

What language is spoken in the home most of the time?
English Spanish Arabic Chinese Hindi Vietnamese Other:            (please specify)

Which best describes your family’s current living situation: 

  • Permanent 

  • Homeless or Emergency Homeless Shelter Battered Women and Children Shelter

  • Living with friend/family member due to loss of housing

  • Hotel/Motel

  • Hospital for 30 days or under

  • Lack permanent nighttime address

  • Insert (Front)

WAGE FORM
NASH/EDGECOMBE PRE-K APPLICATION

To determine eligibility for Nash/Edgecombe pre-kindergarten services it is necessary for you to provide proof of income. 

**If you do not have paystubs, please have your current employer complete and sign the following form. Please list gross wages for 30 days prior to the current month. Please complete for each parent/guardian. 

PARENT/GUARDIAN #1:                              

Employer Name:   Employer Phone #:      
Paycheck received:  Once per week  Every two weeks  Twice per month (ex. 1st & 15th)  Once per month

Please complete using information from the last 30 days – Please Include Overtime

Pay Period

Gross Pay (BEFORE deductions)
Regular Pay
Overtime Pay (IF applicable)
Example: 5/12/19 – 5/25/19
$1,234.56
$1,000.00
$234.56

Employer’s Signature:   Date:       

Employer/Company:                     

Parental Responsibility and Agreement (INITIAL each statement)

Please read carefully and initial each box to confirm your understanding and acceptance of your responsibilities.

INITIAL HERE - PARENTAL RESPONSIBILITY AND AGREEMENT

I give permission for my child to be assessed and referred to the Early Care & Education programs and agencies partnering with Down East Partnership for Children to include Edgecombe County Public Schools, Nash County Public Schools, Nash/Edgecombe Pre-K Programs, Department of Social Services, N.E.E.D, Inc. – Head Start, and the Office of Early Learning and the Division of Child Development and Early Education. I also authorize partnering Pre-K agencies to share my family’s contact information with county partners that serve 4-year-olds, if they believe my child is eligible for other community programs.

I give permission for my family to be referred to Down East Partnership for Children’s Family First Line to assess for additional community resources and to be provided with information about Choosing Quality Childcare.

I understand that if my child is selected for participation, family engagement is expected. I will as a team with my child’s site and teachers to help prepare my child for future success.

I understand that transportation to and from Pre-K programs will be the family’s responsibility. If my Pre-K program offers transportation, I will adhere to the rules and regulations of their transportation policies.

I understand that if there is a change in my child’s address, phone number, or attendance in any type of licensed care, or if there is a change in family size or family income, it is my responsibility to notify Down East Partnership for Children and inform them of any changes.

I give permission for my child to receive a developmental screening and for the results of these screenings to be shared with DEPC and partnering Pre-K Programs.

I understand that my child will need a current immunization record, updated health assessment (including dental, hearing, and vision screenings) within 30 days of their first day attending a Pre-K program.

I understand that my child may be placed on a waiting list.

DELIBERATE MISREPRESENTATION MAY SUBJECT ME TO PROSECUTION UNDER APPLICABLE NC STATE LAWS. MY

APPLICATION PACKET IS COMPLETE, AND INCOME IS REPORTED CORRECTLY. I CERTIFY THAT I AM THE PARENT/LEGAL CAREGIVER OF THE CHILD WHOSE NAME APPEARS ON THIS APPLICATION. YOU MUST SIGN BELOW. 

PARENT/LEGAL CAREGIVER SIGNATURE 

DATE 

**If not the parent, official guardianship/custodianship documentation may be required**