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.
Additional Family Information
1. Does your child have any special needs we should be aware of such as
Trauma: (Please explain)
7. Education / Training(Complete only for parent/guardians living with child)
Transportation: Not available in all areas, specific locations only. Check with individual centers.
(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.