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Smart Start Of Brunswick
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  • About
    • What is Smart Start?
    • Board of Directors
      • Board Meeting Schedule
    • Staff
    • News and Reports
    • Employment
    • Request for Proposals
  • How We Help
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      • Services
      • Job Board
      • Resources
      • Training Calendar
    • Families
      • Programs
      • Family Resources
      • Play Groups & Parent Classes
    • Community
      • Our Supporters
      • Community Partners
  • Get Involved
    • Donate
    • Volunteer Opportunities
    • Advocate
    • Community Events
  • Calendar
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Menu
×
  • Home
  • About
    • What is Smart Start?
    • Board of Directors
      • Board Meeting Schedule
    • Staff
    • News and Reports
    • Employment
    • Request for Proposals
  • How We Help
    • Educators
      • Services
      • Job Board
      • Resources
      • Training Calendar
    • Families
      • Programs
      • Family Resources
      • Play Groups & Parent Classes
    • Community
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NC Pre-Kindergarten Application 2021-2022

Child Information

Gender:(Required)
DOB:(Required)
U.S. Citizen?(Required)
NC resident?(Required)
Race (check all that apply):(Required)
Hispanic/Latino:(Required)

Family Information

Child lives with:(Required)
Are you homeless?(Required)
*If living with legal guardian, legal documentation required

Legal Parent/Guardian/ Stepparent

DOB:(Required)
Race:(Required)
Physical Address:(Required)
Is Mailing Address same as physical address(Required)
Mailing Address (if different from physical address)
Start Date
Employment Status(Required)
Marital Status:(Required)
Education Level:(Required)

Military Status of Parent/Legal Guardian

Military Status of Parent/Legal Guardian

Family Income (Income verification required – Tax returns, W-2’s, pay stubs, child support, Social Security benefits letter, etc.)

Paid
Paid
Paid
Paid
Paid
Paid
Paid
Paid

Child Data

Does your child have a chronic or significant health concern?
Documentation included
Is your child currently receiving services for a developmental or educational need?
Documentation included
Does your child have an active Individual Education Plan (IEP)?
Documentation included
Which one describes who cares for your child routinely (most often):
Attends
Is family currently enrolled in the Child Care Subsidy Program (vouchers)?
List the names of other family members living in the household (18 years of age or younger)(Required)
Name:
Relationship to the Pre-K Child
Date of Birth
Gender
 

Emergency Contact Information (someone living outside of the home)

Family Responsibilities: Please read carefully and initial each box

Family Responsibilities: Please read carefully and initial each box(Required)
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)

Brunswick County NC Pre-K Site Preference: Please check one

Brunswick County NC Pre-K Site Preference: Please check one

Applications will NOT be accepted until all the required documentation has been received.

REQUIRED
Required if listed on the application:
Drop files here or
Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15.
    Drop files here or
    Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15.
      Drop files here or
      Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15.
        Drop files here or
        Accepted file types: jpeg, png, pdf, doc, docx, Max. file size: 50 MB, Max. files: 15.
          Drop files here or
          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.
            Reset signature Signature locked. Reset to sign again
            This field is for validation purposes and should be left unchanged.

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            910-754-3166

            5140 Sellers St., Shallotte, NC 28470

            5140 Sellers St.,
            Shallotte, NC 28470

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