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Financial Assistance Online Application

Child's Name(Required)
MM slash DD slash YYYY
Sex
Have you applied to another Head Start or VPI program 2021-2022?

Parent/Guardian Information

Name(Required)
MM slash DD slash YYYY
Lives with Child(Required)

Parent/Guardian Information

Name
MM slash DD slash YYYY
Lives with Child

Does Your Child Have Insurance?
Insurance
MM slash DD slash YYYY
MM slash DD slash YYYY
Are your child's immunizations up to date

Program Selection

Please 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 choices

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
MM slash DD slash YYYY

Additional Family Information

1. Does your child have any special needs we should be aware of such as
Special Needs 1
Special Needs 2
Special Needs 3
Trauma: (Please explain)

2. Was your family impacted by the COVID-19 pandemic?

3. Does your child receive special education services or related services (have an IFSP or IEP)?

4. Does your child have any chronic health conditions and/or developmental concerns they have seen a specialist for and/or were prescribed medication?

5. Child is a Foster Child?

7. Education / Training(Complete only for parent/guardians living with child)
7. Parent/Guardian 1

7. Parent/Guardian 2

8. Work/School
8. Parent/Guardian 1

8. Parent/Guardian 2
9. Do you receive any of the following?

Transportation: Not available in all areas, specific locations only. Check with individual centers.
10. Available to transport?
To a bus stop?

(Head Start and VPI will need verification of income from the past 12 months)


12. All applicants will have to provide proof of residency.

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.



05/16/2022

Radford Early Learning Center,

1511 Tyler Ave. 

Radford, VA, 24141

(434) 227-7196

Email:

RADFORDCHILDDEVELOPMENT@GMAIL.COM

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