How to Apply

Please read all instructions carefully and answer all questions completely.
Although resumes may be submitted in addition to the information requested on this application, you must submit a completed application to be considered for employment.

Buchanan County Preschool Partnership Application
Buchanan County Head Start and Buchanan County Public Schools

Buchanan County Public Schools Pre-K Program
Lauralee Jackson, Title I Supervisor
P.O. Box 833, Grundy, Virginia 24614
Phone: 276.935.4551 Fax: 276.935.4480

Buchanan County Head Start
Jennifer Ratliff, Director
P.O. Box 1167, Grundy Virginia 24614
Phone: 276.935.2333 Fax: 276.935.1943

Enroll Applicationtion

Eligible Buchanan County Public School Attendance Zone(Required)

Child's Information

Child's Full Name(Required)

First Middle Last

Date of Birth(Required)

Place of Birth(Required)

After submitting application, please call 276.935.2333 to provide us with the Birth Certificate #.

Date Issued

Ethnic Group(Required)

Caucasian

African American

Hispanic

Asian/Pacific Islander

American Indian

Other

Gender(Required)

Male

Female

Is English your primary language?(Required)

Yes

If no, what is your preferred language?

Physical Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address if different than Physical

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Will Child ride a Bus?(Required)

Yes

Number of miles from School?(Required)

Please enter a number from 0 to 300.

Name of county and community in which child lives?(Required)

Directions to home

Parent/Guardian #1 Information

Name(Required)

First Last

Parent/Guardian #1(Required)

Father

Mother

Stepfather

Stepmother

Grandparent

Foster Parent

Legal Gaurdian

Date of Birth(Required)

Place of Birth(Required)

Lives with Child?(Required)

Yes

If no, What is the address?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Cell Phone

Email(Required)

Employment Status(Required)

Full-Time

Part-Time

Unemployed

Employer

Employer Phone Number

Employer Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 Information

Name

First Last

Parent/Guardian #1

Father

Mother

Stepfather

Stepmother

Grandparent

Foster Parent

Legal Gaurdian

Date of Birth

Place of Birth

Lives with Child?

Yes

If no, What is the address?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Cell Phone

Employment Status

Full-Time

Part-Time

Unemployed

Employer

Employer Phone Number

Employer Address

Street Address Address Line 2 City State ZIP Code

Family Infornation

Family Information Area List other children under 18 living in household.

Child 1 Name

First Last

Child 1 Gender

Male

Female

Child 1 Date of Birth

Child 1 Current School

Child 2 Name

First Last

Child 2 Gender

Male

Female

Child 2 Date of Birth

Child 1 Current School

Child 3 Name

First Last

Child 3 Gender

Male

Female

Child 3 Date of Birth

Child 3 Current School

Child 4 Name

First Last

Child 4 Gender

Male

Female

Child 4 Date of Birth

Child 4 Current School

Child 5 Name

First Last

Child 15Gender

Male

Female

Child 5 Date of Birth

Child 5 Current School

INSURANCE INFO

Medicaid Number

FAMIS Number

Other

Specify

Number

INCOME INFORMATION

Total Number of Members in Household

Please enter a number from 0 to 20.

Total Income (ALL sources) $

Income Tax Form 1040A or 1040

Social Security Implement (SSI)

Please state amount of benefit, if applicable

Social Security Benefits

Please state amount of benefit, if applicable

W-2 Form

Pay Stubs

Unemployment

Please state amount of benefit, if applicable:

Compensation

Please state amount of benefit, if applicable:

Child Support

Please state amount of benefit, if applicable:

Temporary Assistance for Needy Families (TANF)

Please state amount of benefit, if applicable:

Parents Declaration of Zero Income:

(See attached written statement from parent)

If zero income, state reason:

EMERGENCY CONTACT INFO

(List two people other than parents who can be contacted in case of emergency)

Emergency Contact Name Primary

First Last

Emergency Contact Primary Phone

Emergency Contact Name Secondary

First Last

Emergency Contact Secondary Phone

Childs Physician

First Last

Childs Physician Number

AT RISK INFORMATION

Is your family currently receiving any forms of income and/or assistance? Please check all that apply.

Do any of the following situations apply to your family? Please check all that apply.

SCHOOL INFORMATION

Highest Grade Completed:

Education

High School Graduate/GED

Some College

College Graduate

AGREEMENT I have reviewed this information and certify that everything on this application is correct, to the best of my knowledge. I understand that deliberate misrepresentation of any of this information will disqualify my child from being considered for a preschool program. I understand that Buchanan County Public Schools and Buchanan County Head Start work in partnership. I give permission for the release of information regarding my child’s screening, eligibility, and enrollment between Buchanan County Public Schools and Buchanan County Head Start. Information will be handled confidentially.

Parent/Legal Guardian Signature

Date