NC Pre-Kindergarten Application 2021-2022 Child InformationChild’s Full Name:(Required) Gender:(Required) Male Female DOB:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age:(Required) U.S. Citizen?(Required) Yes No NC resident?(Required) Yes No County of residence:(Required) Race (check all that apply):(Required) White Native Hawaiian/Pacific Islander Black Asian Native American Indian/Alaska Native Other (specify): Other (specify): Hispanic/Latino:(Required) Yes No Family InformationChild lives with:(Required) Both parents Mother Father Stepparent Foster-Parent Other* Other* (specify) Are you homeless?(Required) Yes No *If living with legal guardian, legal documentation requiredLegal Parent/Guardian/ StepparentFull Name:(Required) DOB:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Race:(Required) White Black Other Race: Other: Physical Address:(Required) Street Address City State ZIP / Postal Code Is Mailing Address same as physical address(Required) Yes No Mailing Address (if different from physical address) Street Address City State ZIP / Postal Code Email(Required) Home PhoneCell PhoneWork PhonePlace of Work:(Required) Start DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employment Status(Required) Employed Full Time Employed Part Time Seeking Employment Self Employed Currently attending college Stay at home parent In high school or GED program Other Employment Status-Other Marital Status:(Required) Single Married Separated Divorced Widow/Widower Education Level:(Required) Less than high school GED/High School Diploma Some College Associate Degree Bachelor Degree Graduate Degree Military Status of Parent/Legal GuardianMilitary Status of Parent/Legal Guardian Active duty in US Armed Forces Reserve unit of Armed Forces and ordered to active duty in past or next 18 months One parent or legal guardian of this child was injured or killed while on active duty NA Family Income (Income verification required – Tax returns, W-2’s, pay stubs, child support, Social Security benefits letter, etc.)Father’s Income BEFORE Taxes Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Mother’s Income BEFORE Taxes Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Stepparent’s Income BEFORE Taxes Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Child Support Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Alimony Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Worker’s Comp Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Unemployment Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Social Security /Retirement Paid Yearly Monthly Twice Monthly Bi-Weekly Weekly Child DataChild’s First Language: Language spoken in the home: Does your child have a chronic or significant health concern? Yes No If yes, please explain: Documentation included Yes No NA Is your child currently receiving services for a developmental or educational need? Yes No If yes, please explain: Documentation included Yes No NA Does your child have an active Individual Education Plan (IEP)? Yes No Documentation included Yes No NA Date of IEP: Which one describes who cares for your child routinely (most often): My child has never attended childcare, family childcare, or preschool. In the past, my child attended childcare, family childcare, or preschool. My child is currently attending the following childcare, family childcare, or preschool: Program name: Program name: Attends full-time part-time Third Choice Is family currently enrolled in the Child Care Subsidy Program (vouchers)? Yes No What is the child’s family size: Total Number? List the names of other family members living in the household (18 years of age or younger)(Required)Name:Relationship to the Pre-K ChildDate of BirthGender Add RemoveEmergency Contact Information (someone living outside of the home)Emergency contact:(Required) Reationship to child(Required) Home Phone:(Required)Cell PhoneWork PhoneFamily Responsibilities: Please read carefully and initial each boxFamily Responsibilities: Please read carefully and initial each box(Required) I understand my child may be placed on a waiting list. I understand that my child will need a current/updated health assessment. I understand that transportation to and from the NC Pre-K program will be the family’s responsibility. I understand that family involvement is expected in the NC Pre-K program. I understand my child will receive developmental, dental, hearing, vision, and language screenings. I will provide NC Pre-K program with any needed/required documentation. I give my permission for Smart Start of Brunswick County to share my child’s IEP with childcare center staff and teachers. I also give my permission for Smart Start of Brunswick County to share the classroom location of my child with the Brunswick County Schools Exceptional Children’s Program staff (if applicable).(Required) Yes No Brunswick County NC Pre-K Site Preference: Please check oneBrunswick County NC Pre-K Site Preference: Please check one Earth Angels Educational Center – 720 Whiteville Rd., Shallotte, NC For Kids Only – 344 Mulberry Rd., Shallotte, NC Kids World Academy III – 9272 Post Office Rd., Leland, NC Little Sandpipers Learning Center – 972 Old Ocean Highway, Supply, NC Excel 5 – 111 Thomas Garst Lane, Leland, NC Child Care Network #84 – 787 Village Rd., Leland, NC Child Care Network #85 - 802 Leonard St., Southport, NC Tiny Tots – 270 Union School Rd., Shallotte, NC The Kids Connection – 4929 Old Shallotte Rd., Shallotte, NC No preference (child will be placed at the closest childcare site to the home address) Applications will NOT be accepted until all the required documentation has been received.REQUIRED Completed and signed application Copy of child’s birth certificate Copy of child’s immunization record Proof of all sources of income: 2020 IRS tax return; 2020 W2; current LES; a month of current/consecutive pay stubs; written statement from employer stating wage, hours employed and frequency of payment. Additional income: child support, alimony, Social Security benefits letter, Employment Security Commission letter, retirement, etc. Proof of residency: CHOOSE ONE - driver’s license with current address, current utility bill, signed lease agreement (if bill/rental agreement is in someone else’s name, a signed statement must be provided by the person along with the bill/rental agreement) Legal document required for guardianship/custody if not living with biological parent Select AllRequired if listed on the application: Documentation of parent/legal guardian’s military services (active duty or death from military service) Copy of child’s current Individualized Education Plan (IEP) Documentation of chronic illness – child’s health assessment of documentation from medical professional Copy of current educational/developmental screenings/evaluation indicating developmental or educational need Copy of child’s birth certificate ( File Upload)(Required) Drop files here or Select files Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15. Copy of child’s immunization record (File Upload )(Required) Drop files here or Select files Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15. Proof of Income (File Upload )(Required) Drop files here or Select files Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15. Proof of Residency (File Upload )(Required) Drop files here or Select files Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15. IEP (File Upload ) Drop files here or Select files Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15. Parent/Legal Guardian Signature I certify that I am the parent/legal guardian of the child for whose name appears on this application. I certify that all the information contained in this application is accurate and complete to the best of my knowledge including income information. If at any time my family situation changes, I will notify your office of said changes. Some changes may require a new application to be completed. Signature Reset signature Signature locked. Reset to sign again CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
