NC Pre-K Application Assessment QuestionnaireFranklin County

The NC Pre-K Program is a program of the Division of Child Development and Early Education in the North Carolina Department of Health and Human Services. The NC Pre-K Program is designed to provide high-quality educational experiences to enhance school readiness for eligible four-year olds.

Instructions to complete application:

Please complete one application for each eligible child. A child must be 4 years of age on or before August 31st to be eligible A child Health Screening conducted within 12 months is required within 30 days of program entry to the

NC Pre-K Program. A Dental Screening by a dentist or dental hygienist conducted with 12 months of NC Pre-K Program

entry is also required. Fees may apply for transportation and food nutrition costs. Parent Co-Payments may apply to families of eligible children that do not meet NC Pre-K Program risk

factors. Must provide proof of child eligibility with application (birth certificates, income documents, etc.)

NC Pre-K Site Locations: (Please select site preferences below by entering 1, 2, 3 on the blank lines

_1.ABC Adventures_2.Bunn Head Start

_3.Laurel Mill Elementary _4.Louisburg Elementary _5.Nelson Head Start _6.Royal Elementary School _7.Edward Best Elementary _8.Franklinton Elementary _9.Long Mill Elementary _10.Children’s Ark _11.Dream World Academy

*The NC Pre-K Coordinator will notify families of children who meet eligibility requirements for NC Pre-K services and site administrators will determine child placement. (A child waiting list may apply.)

Mail NC Pre-K application(s) to: NC Pre-K Program Coordinator FGV Smart Start, Inc. PO Box 142 Henderson, N.C. 27536

The contact person for Franklin County NC Pre-K: Catherine Sledge, FGV Smart Start NC Pre-K Program Coordinator

252-433-9110, extension 2381

NC Pre-K ApplicationFranklin County

Child’s Legal Name, Last: First: Middle:

Date of Birth: Was this child born in the U.S.A.?

Sex:Male Female

Child’s Social Security Number:

Child’s Race: White Black Hispanic Asian Indian

Child lives with: Relationship to child:

Street Address: How long have you lived at this address?

City: State: Zip Code: County of residence:

Phone: Home Work Cell Message Alternate Phone: Home Work Cell Message

Is the child currently in child care/day care/Head Start or any other Pre-K Program? No Yes

Did the child have difficulty adjusting to previous child care/day care/Head Start? No Yes, describe:__________

Has the child previously been in child care/day care/Head Start or any other Pre-K Program? No YesIf yes to the questions above, please list:Name of Child Care Program(s) / How long child has attended:________________________/____________________________(see page 4 for additional space to add multiple programs)What was the last date child attended child care program/location? ____________.

Does the child have any serious illnesses or handicapping conditions?

No Yes, describe:_________________

Has the child had a formal developmental evaluation? (Ex:. CDSA) No Yes

Child’s Health Status: (choose one)

child has no significant health concerns

child is seen or being seen by a pediatric specialist for chronic health concerns

child is identified as mentally or physically chronically ill or medically fragile

Employment Status Highest Level of Education

Language(s) Spoken

Mother’s Information:

Name: __________________________________________

Marital Status: Single Married Separated Divorced

Currently residing in the home with the child? Yes No

Employed Full-timeWhere___________How long_________

Employed Part-timeWhere___________How long_________

UnemployedDisabled

Still in high school

Dropped out of school

GEDSome collegeCollege Graduate

Level: AA BS MS

Check all that apply:

EnglishEnglish as a

2nd LanguageSpanishOther:____

__

Father’s Information:

Name: ____________________________________________

Marital Status: Single Married Separated Divorced

Currently residing in the home with the child? Yes No

Employed Full-timeWhere___________How long_________

Employed Part-timeWhere___________How long_________

UnemployedDisabled

Still in high school

Dropped out of school

GEDSome collegeCollege Graduate

Level: AA BS MS

Check all that apply:

EnglishEnglish as a

2nd LanguageSpanishOther:____

__

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Family Size (how many in actual family):

Gross Income of Child’s Actual Family: __________

Weekly Monthly Yearly

Number of Adults (age 18 & over) residing in Child’s Household:______________Has one or more parent been placed on a deployment list yes no

Number of Children (under age 18) residing in Child’s Household:

Please do not return application without: Copy of Birth Certificate Copy of Social Security Card Family Income Documentation (Check stubs, etc.) An application that does not include the documentation cannot be processed. It is required that the entire application be completed.  Incomplete applications cannot be processed. Military Status Verification: Military Status must be verified via the Military Member’s Leave & Earnings

Statement

Parent/Guardian AcknowledgementI understand by submitting this application that my child will be assessed for the North Carolina Pre-Kindergarten program. I understand if my child qualifies for the North Carolina Pre-K program, parent involvement will be critical to the success of my child. I/We will commit to participate as required by the criteria of the Pre-K program.

Assurance Statement:I CERTIFY THAT I AM THE PARENT/GUARDIAN OF THE CHILD FOR WHOM THIS APPLICATION IS BEING MADE AND THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT.

________________________________________ _____________Parent/Legal Guardian (required) Date

Franklin County

North Carolina Pre-K ProgramSite Locations

ABC Adventures, Inc. Bunn Head Start Dream World Academy118 Industrial Drive 750 Bunn Elementary Road 130 Savage StreetLouisburg, N.C. 27549 Zebulon, N.C. 27597 Franklinton, N.C. 27525Site Administrator: Valerie Weston Site Administrator: Lisa Mosley Site Administrator: Renee MuldrowTelephone: (919)496-2886 Telephone: (919)496-0175 Telephone: (919) 494-2177

Laurel Mill Elementary School Louisburg Elementary Nelson Head Start730 Laurel Mill Road 50 Stone Southerland Road 102 Leonard Farm RoadLouisburg, N.C. 27549 Louisburg, N.C. 27549 Louisburg, N.C. 27549Site Administrator: Genie Faulkner Site Administrator: William Harris Site Administrator: Lisa Mosley Telephone: (919)853-3577 Telephone: (919)496-3676 Telephone: (919)496-4585

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Royal Elementary School308 Flat Rock Church RoadLouisburg, N.C. 27549Site Administrator: Shawnee Perry-ManleyTelephone: (919) 496-7377

Edward Best Elementary School 4011 Highway 56 EastLouisburg, NC  27549Site Administrator:  Debbie AyscueTelephone: (919) 853-2347

Franklinton Elementary School431 South Hillsborough StreetFranklinton, NC  27525Site Administrator:  Carol DavisTelephone:  (919) 494-2479

Long Mill Elementary School1753 Long Mill RoadYoungsville, NC  27596Site Administrator:  Kim FerrellTelephone:  ( 919) 554-0667

Children’s Ark 404 South Cross StreetYoungsville, NC  27596Site Administrator:  Jennifer TippettTelephone:  (919) 556-7222

Name of Child Care Program(s) How long did child attend?

1._________________________ ______________________2._________________________ ______________________3._________________________ ______________________4._________________________ ______________________

5._________________________ ______________________

Child placement in the NC Pre-K Program is contingent upon funding.

END

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