Financial Assistance Online Application Child's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Sex Male Female Other Physical Residence(Required) Mailing Address (if different from physical) Current and past preschool / child care programsHave you applied to another Head Start or VPI program 2021-2022? Yes No Parent/Guardian InformationName(Required) First Last Relationship(Required) Date of Birth(Required) MM slash DD slash YYYY Lives with Child(Required) Yes No Employer(Required) Total Hours per Week(Required)Work Phone #(Required)Home Phone #(Required)Email(Required) Parent/Guardian InformationName First Last Relationship Date of Birth MM slash DD slash YYYY Lives with Child Yes No Employer Total Hours per WeekWork Phone #Home Phone #Email Does Your Child Have Insurance? Yes No Insurance Private Medical Insurance Private Dental Insurance Medicaid Date of child's Last physical MM slash DD slash YYYY Date of child's last dentist visit MM slash DD slash YYYY Are your child's immunizations up to date yes No Program SelectionPlease consider my child for the following program(s). I understand that there are limited spaces available in all programs. Please list 1s, 2nd, 3rd, 4th and 5th choicesFirst ChoiceHead Start full day school day located at 1st Baptist for 3-year oldsHead Start full day school day located at McHarg Elem School for 4-year oldsRadford City Public Schools Virginia Preschool Initiative (VPI)New River Community College / Head Start full day services (Full time NRCC Students only)Mixed Delivery Preschool for 3- and 4-year-olds with before and after school hours provided at Radford Early Learning CenterSecond ChoiceHead Start full day school day located at 1st Baptist for 3-year oldsHead Start full day school day located at McHarg Elem School for 4-year oldsRadford City Public Schools Virginia Preschool Initiative (VPI)New River Community College / Head Start full day services (Full time NRCC Students only)Mixed Delivery Preschool for 3- and 4-year-olds with before and after school hours provided at Radford Early Learning CenterThird ChoiceHead Start full day school day located at 1st Baptist for 3-year oldsHead Start full day school day located at McHarg Elem School for 4-year oldsRadford City Public Schools Virginia Preschool Initiative (VPI)New River Community College / Head Start full day services (Full time NRCC Students only)Mixed Delivery Preschool for 3- and 4-year-olds with before and after school hours provided at Radford Early Learning CenterFourth ChoiceHead Start full day school day located at 1st Baptist for 3-year oldsHead Start full day school day located at McHarg Elem School for 4-year oldsRadford City Public Schools Virginia Preschool Initiative (VPI)New River Community College / Head Start full day services (Full time NRCC Students only)Mixed Delivery Preschool for 3- and 4-year-olds with before and after school hours provided at Radford Early Learning CenterFifth ChoiceHead Start full day school day located at 1st Baptist for 3-year oldsHead Start full day school day located at McHarg Elem School for 4-year oldsRadford City Public Schools Virginia Preschool Initiative (VPI)New River Community College / Head Start full day services (Full time NRCC Students only)Mixed Delivery Preschool for 3- and 4-year-olds with before and after school hours provided at Radford Early Learning Center If my child is chosen as part of the Mixed Delivery Grant, I do/do not consent for his/her photograph to be shared with the granting agency.Consent I agreeDate MM slash DD slash YYYY Additional Family Information1. Does your child have any special needs we should be aware of such asSpecial Needs 1 Developmental Delay Autism Hearing Impairment Special Needs 2 Speech /Language Disorders Traumatic Brain Injury Orthopedic impairment or physical limitations Special Needs 3 ODD, OCD, ADHD Visual Impairment Diagnosed Medical Condition Trauma: (Please explain)Trauma 2. Was your family impacted by the COVID-19 pandemic? Yes No Please list and explain 3. Does your child receive special education services or related services (have an IFSP or IEP)? Yes No 4. Does your child have any chronic health conditions and/or developmental concerns they have seen a specialist for and/or were prescribed medication? Yes No please list and explain 5. Child is a Foster Child? Yes No 6. Primary Language in household?AfrikaansAlbanianArabicArmenianBasqueBengaliBulgarianCatalanCambodianChinese (Mandarin)CroatianCzechDanishDutchEnglishEstonianFijiFinnishFrenchGeorgianGermanGreekGujaratiHebrewHindiHungarianIcelandicIndonesianIrishItalianJapaneseJavaneseKoreanLatinLatvianLithuanianMacedonianMalayMalayalamMalteseMaoriMarathiMongolianNepaliNorwegianPersianPolishPortuguesePunjabiQuechuaRomanianRussianSamoanSerbianSlovakSlovenianSpanishSwahiliSwedishTamilTatarTeluguThaiTibetanTongaTurkishUkrainianUrduUzbekVietnameseWelshXhosa 7. Education / Training(Complete only for parent/guardians living with child) 7. Parent/Guardian 1 Did Not Finish High School (Last grade attended) Has GED/Diploma Some College/Associate’s Degree/ Other Training Has College Degree (Bachelor’s or above) Description 7. Parent/Guardian 2 Did Not Finish High School (Last grade attended) Has GED/Diploma Some College/Associate’s Degree/ Other Training Has College Degree (Bachelor’s or above) Description 8. Work/School 8. Parent/Guardian 1 Not employed Work 29 hours or less/week Work 30+ hours a week School part-time School full-time School Credit Hours8. Parent/Guardian 2 Not employed Work 29 hours or less/week Work 30+ hours a week School part-time School full-time School Credit Hours9. Do you receive any of the following? Housing/Rental Assistance TANF SSI Transportation: Not available in all areas, specific locations only. Check with individual centers.10. Available to transport? Yes No To a bus stop? Yes No What prevents you from being able to transport your child? 11. Your total annual family income(Head Start and VPI will need verification of income from the past 12 months) 12. All applicants will have to provide proof of residency. 13. How did you hear about our program? New River Community Action Head Start, Radford City Schools, and United Way of Southwest Virginia takes into consideration a number of factors in order to determine eligibility. In addition to your income level and the age of your child, other children, and family needs are noted. The following information is voluntary. This information will be considered along with other information shared with our staff during the application process in order to determine eligibility and become familiar with your family. By signing the application below, I authorize the release of all medical, dental, educational, and developmental information to be shared by New River Community Action Head Start, Radford City Schools, and United Way of Southwest Virginia. Signature(Required) 05/16/2022
