Skyline CAP Head Start Serves children ages 3.& 4 School Readiness with vetted curriculum & teacher observations through C.LA.S.S Preschool classes held ‘Monday through Friday Family support services provided & Parent Participation Encouraged Eligibility includes assessment of family risk and needs assessment Income level requirement For more information call 540- 948-3916, x 210 (regional office) or x 272 (local), Preschool Services In Shenandoah County ‘Ages are based on status ‘as of September 30 + SIOLINE CAP. HEAD START. + VIRGINIA PRESCHOOL, INETIATIVE ATPUBLIC scHOOLS + VIRGINTA PRESCHOOL INITIATIVE AT PRIVATE PK + IAIGRANT EDUCATION + EARLY CHILDHOOD 'SPECTAL EDUCATION PLAY Is 4 CHILD'S WORK Migrant Education Serves children 3-21 years of age Assists with enrolling children in an educational program ‘Serves persons who have resided in the county for less than 3 years (One parent/guardian is employed in an egricultural/poultry position which is highly mobile, seasonal, or migrant Home-school liaison Promotes parental involvement For more information Call 540-568-3666. Community Private Partners Virginia Preschool Initiative & Mixed Delivery Private PK Serves 3 & 4-yr-olds School Readiness Focus Monday through Friday/Full and Half Day Family Engagement Eligibility & services include assessment of family risk and needs VDOE Vetted Curriculum Va Quality Participants Teachers Observed ‘through CLA.S.S Programs tha receive public funds benefit from measurement and supports for improvement ‘through VQUS, ensuring quality choles ere ovale fora familie For more information Call 540-459-4121, ‘Shenandoah County Public ‘Schools Early Childhood ‘Special Education Serves children 2-4 years of age Screens to determine if delays or disabilities that require special education services are present Individualized Educational Plans (LEP) TEP may recommend home-based instruction, center-based and inclusive classrooms, hearing, vision, family ‘support or other services For more information Call 540-459-4121, ‘Shenandoah County Public Schools Virginia Preschool Initiative Serves 4-yr-olds School Readiness Focus SCPS VPI classes follow public school schedule Family Engagement Eligibility & services include assessment of family risk and needs Scheel Bus Transportation Ts Available VDOE Vetted Curriculum Va Quality Participants Teachers Observed through C.L.A.S.S Progra that receive public funés bereft from measurement and supports for improvement “through VQBS, encring quclty choices are evel fra ‘miles. For more information Call 540-459-4121.‘Skyline CAP Head Start Servicios para nifios entre 3 y 4 allos de edad Programa de preparacién escolar Clases preescolares de lunes a viernes Servicios de apoyo a la fatmilia Para ser elegible necesita tuna evaluacién del riesgo de la familia y de las necesidades, Evidencia de ingreso Se anima la participacign de los padres Para més informacién Llame 0 540-948-3916, x 210 (regional of fice) or x 272 (local). Servicios Preescolares en el Condado de Shenandoah = SKYLINE CAP HEAD START = (SCPS) LA INICEATIVA PREESCOLAR DE VIRGINIA = (PRIVADO) LA INICIATIVA PREESCOLAR DE VIRGINIA + EDUCACION MIGRANTE + EDUCACION ESPECIAL DE LA NINEZ TEMPRANA JUGAR ES EL TRABAJO DE Los NrNios EL Programa de Educacién Migrante (M.E.P.) Servicios para nifios entre 3 y 21 affos de edad Ayuda a inscribir a los nifios ‘en un programa educative ‘Ayuda a personas que han vivido en el condado por menos de 3 affos. ‘Un padre/quardién tiene que ‘trabajar (0 haber trabajado) en una planta de pollo 0 otro tipo de trabajo con un producto vivo. Enlace entre hogar y escuela Promueve la participacién de los padres Para més informacién Llame a 540-568-3666. Preescolar Privado: La Thiciativa Preescolar de Virginia (W.P.Z. y Mixed-Delivery) * Servicios para nifios de 4 y 3 afios de edad Para ls niflos que no pueden asistir a Head Start Preparacién para la escuela Clases preescolares de ‘acuerdo con el horario de la escuela publica, Servicios de apoyo a la familia Elegibilidad por una cevaluacién del riesgo de la farnilia y las necedades. Participacién de los padres Para més informacién Uame a 540-459-4121, ‘Shenandoah County Public ‘Schools Educacién Especial de La Nifiez Temprana (Special Education) Servicios para nifios entre 2y 4 aitos de edad Determina si el/la niio/a tiene retraso en su desarrollo o una discapacidad que requiere ceducacién especial Plan Educativo Individualizado (IEP) TEP puede recomendar instruccién en casa, clases inclusives en el centro, ofdo, visién, apoyo a la familia y otros servicios Para més informacién Lame 540-459-4121. Las edades estén basadas en la edad de los nifos a partir del 30 de Septiembre ‘Shenandoah County Public Schools La Thiciativa Preescolar de Virginia ‘Servicies para nitios de 4 Pra los nifios que no pueden ‘sistir a Head Start Preparacién para la escuela Clases preescolares de ‘acuerdo con el horario de la escuela pablica, Servicios de apoyo a la familia Elegibilidad por una ‘evaluacién del riesgo de la familia y las necedades. Transportacién serd proveida Participacién de los padres Para més informacién Lame a 540-459-4121.Shenandoah County Preschool Services Enrollment Application Letter Information PLEASE KEEP THIS COVER SHEET FOR FUTURE REFERENCE Preschool Services do not alscriminate on the basis of race, coor, religion sex, national origin, or handicap. CONFIDENTIAL Children must have reached the required age by Seplember 30 of the enrollment year. INSTRUCTIONS FOR APPLICATION PROCEDURE - If you need assistance or have questions, call any of the numbers below. v Complete the attached application Y Birth certificate (copy) v Proof of total household income from all sources If you ate applying only to have your child’s language or development evaluated, income proof is NOT required, Please send COPIES of the following documents: W-2s or tax return for the previous year or > Pay check stubs for the last month or > Letter from your employer with income information or > SNAP authorization letter a If the following income applies we also need verification. > SSI or SSDI(award letter) Cash assistance (TANF) (DSS award letter) Child Support (award letter or copy of checks) Veteran's Benefits Social Security Unemployment > Worker's Comp * Ifyou have NO income we must have a letter of support from the person(s) supporting your family or a Zero-income statement, which can be sent upon request. f you are homeless (had to move in with friendsifamily) you need to complete a living situation survey, which can also be sent upon request. vy vvyy Upon receipt of al ofthe above needed information you will bo notified of your child's application status. This could take up to 30 «days and unfortunately sometimes longer. Submitting this application does not mean that the child is enrolled. {your child is selected for a program, required documents may include an update-to-date immunization document, school entrance physical, residency documentation, and other items, including a dental exam for some preschool services. Ifyour address or telephone number changes please contact us with the changes. Please return your application to one of the following addresses: Skyline CAP Head Start, P. 0. Box 588 (532 South Main St.), Madison, VA 22727 (Fax) 540 948-2264 Main Office: 540-948-3916 ext.210; Shenandoah office: ext 272 (127 East High St, Woodstock) Or email farnilymanager@skylinecap.org Shenandoah County Public Schools, Preschool Coordinator 1251 Susan Avenue, Woodstock, Va 22664 (Office) 540-459-4121 (Fax) 540-459-5965 Or Email sdritter@shenandoah.k12,va.us Policy Council Reviewed Approved: 01/29/21 03/31/22/ApplicationLetterEnglishCondado de Shenandoah Programas de Preescolar Informacién del Formulario de Inscripcion POR FAVOR GUARDE ESTA HOJA PARA REFERENCIA. 1s Programas no dlscriinan a base de raza, olor, regi, exo, origen nacional, oicopacidades CONFIDENCIAL Nios tienen que cumplirafios necesario antes del 30 de septiembre del alo de inscriocion. INSTRUCCIONES PARA SEGUIR CON EL FORMULARIO DE INSCRIBIR — ‘Si necesite asistencia o tiene preguntas, llame cualquiera de los numeros abajo. ¥ Cumpla el formulario juntado Y Certificado de nacimiento v Sujeta prueba de ingresos totales para toda la familia al formulario, Si usted s6lo quiere que su nitio reciba una evaluacién de desarrollo © discurso, eomprobacién de ingresos NO ES NECESARIO. Por favor mande COPIAS de lo siguiente: > La forma W-2 0 el retorno de impuestos del afio pasado 0 » Los talonarios de pago para el ultimo mes 0 > Carta de empleo con informacion de ingresos © > SNAP Ia informacién Si aplique lo siguiente, también necesitamos verificacién. ‘SSI or SSDI (carta de notificacién) Asistencia financiera (TANF) (DSS carta de notificacién) Child Support (carta de notificacién o copia de cheques) Boneficios de Veteran Seguridad Social Desempleo. Worker's Comp ‘Sino tiene ingresos, debemos tener una carta de apoyo de la(s) Persona(s) que respalda a su familia 0 un estado de cuenta de cero ingresos, que podemos enviarle a pedido. Sino tiene hogar {tuvo que mudarse con amigos/familiares) debe completar una encuesta de situacion de ida, que Podemos enviarle a pedido. vyvvvyy Después de que recibamos toda la informacién de arriba, usted séra notificado del estado de su nifio en el programa, El proceso puede tomar 30 dias 0 mas. El envio de esta solicitud no significa que el nifo esté ‘martriculado. Si se elige a su hijo para el programa, los documentos que se requireren incluir un registro de vacunacién, examen fisico, un examen dental y otros documentos. Si su direccién 0 ntimero de teléfono cambie durante que nos esperes, por favor llémenos con los cambios. Por favor devuelve el formulario a uno de estes dirrecio ‘Skyline CAP Head Start, P. 0, Box 588 (532 South Main St.), Madison, VA 22727. Fax: 540 948-2264; Oficina central: 540 948-3916 ext 210; 0 email familymanager@skylinecap.org Oficina Shenandoah: ext 272, 127 East High Street, Woodstock Shenandoah County Public Schools, Preschool Coordinator 1251 Susan Avenue, Woodstock, Va 22664; (Oficina) 540 459-4121 (Fax) 540 459-5965 © Email sdritten@shenandoah.k12.va.us Policy Council Approved: 01/29/19 (03/31/22/ApplicationCoverLetterSpanishAPPLICATION FOR PRESCHOOL SERVICES IN SHENANDOAH COUNTY CONFIDENTIAL = 4PLICACION DE CONDADO DE SHENANDOAH PROGRAMAS DE PRESCOLAR CONFIDENCIAL Preschool Serdces do not discriminate an the basi of race, coor, religion, sex, national origi, or handicap. as Programas no dscriminan a base de razo, color, religin, sexo, orien nacional. incopacidades Please indicate any service(s) you are applying or looking for: © *Speech andlor Developmental Screening 8 Chid Care Subsidy cMigrant Education 1 Private Preschool Virginia Preschool Intative Classroom at Public School c Virginia Preschool IntiaiivelMixed Delivery at Private Preschool 2 Head Start Classroom Ido not know *PART A (‘Screening roferrals for pocial education: Complete Part A only. Si soo busca una evalucion complete solo a Parte A) Full Name of child - Nombre del Nifio | Birth date-Fecha de | Birthplace: Lugar de | Race-Raza Nacimiento Nacimiento Male—Nito —Female- Nite |Current Child Care Provider: Hispanics yes o No Hispanos: a $i_oNo Mother/legal guardian name -Nomire dela madre o guardién | Father/legal guardian name-Nombre del padre o guardian legal legal Relationship to child ~ Relacién al Nifto 0 Parents ~ Padres cGrandparents — Abuelos _o Faster parent — Padres de Cvianza 12 Other relative — Otros parianies_a Person having legal custody/guardianship ~ Persona quo fiane custodia legal Mailing Address-Direccién de Correo ‘Street Address-Direccian Actual City, State, Zip-Ciudad, Estado y Cédigo Postal City, State, Zip -Ciudad, Estado y Cédigo Postal Wothars address eiforont- Us Wecaan dela Wako a Serene Father's adevoas differant a craccin del pare a aerate “Email address Direccién de correo elecirénico Mom/Madre: Dad/Padre: How many years have you lived in this County? 1 Cuéntos afios has vivido en este condado? HomeiGell Phone #- Numero de | If no phone -Message phone, Does child have any allergies ?-; iene | dolefono en cees, name & # - Sino hay teléfono - Namero de su hijo/a alergias? jee feléfono para recados, y nombre If so, explain: - Siasi, explique. Primary language spoken in the | What language does the child speak at Tow well does the child speak English?= hhome—ldioma principal que se | home? Qué iciome habia su hija en case? _| Cémo habla su hjofa e inglés? habla en casa SWell-6ion > Not well-No muy bien c None Nada Name/telephone number of interpreter if needed: Nombre y numero de teléfono del intérprete si es necesario, si tiene uno EMERGENCY CONTACTS (Contacios De Emargencia). z. (Namoitinddress, Nombre, 4, Domictio) What is your child's medical insurance? ZGu8 sepure médico Fone Su hoa? Doctor's Name What is the insurance number? Cue! ese! nimero cel seguro medica? Dentist Name. Please indicate any of the following services your child Is receiving — Por favor ndigue os senisos que eu nfo’ esta recbendo. Does your child have an IEP? ¢Tiene su hioun IEP? Yes -0 Si_ No - cNo ‘a0ccupational Therapy/Physical Therapy-—Terapia Ocupacional/Terapia Fisica ‘Speech/Language — Habie/idioma cHearing — Odo Vision ~ Vista Developmental — Desarrollo Other = Otro _ (Specify - Especifique): Do you have any concerns about your child's development or speoch/language? iene aguna reocipasn sobre el dasaralo de suhjo.Hadladoma? aYes -0 Si No - aNo Please describe your concern if you have one (add a page, if needed): ‘Stes asi expique, por favor (Agregue una pagina, si necesito Tauthorize Shenandoah County Preschool Services to screen the above named individual in order to determine the best service delivery for my child. Autorizo Servicios Preascolares de! Condado de Shenandoah para evaluar a fos individuos arriba, nombradoes determiner fa major entrega del servicio para mi nti. Parent/Guardian Signature Firma de padre/madre/tutor: Date Fech; PC approval: Board approval (03/3 1/22/EnrollmentApplication/English/SpanishPART B (Parte B para clases de preescolar, por ejemplo: Head Start, VPI) Do you have transportation available to get your child to and from the classroom? Tene usted transporte isponsibe para levara su rife/a. la esouele? Yes -a Si_aNo - oNo Name of all househord members Hombres | Bae] FM Where do you work?” | Emplyertel favo | Heino Nombre de todos los miambros del hogar fastace | ican | = (marque lo 1 Significant behavior a ADHD c special dietary needs, Gon prescription medications Conducta o f discurso signiicativos conciemen, el peso bajo del nacimiento, o las necesidades utreienaies on ymedleacion 1 Single parent, incarcerated parent, or u parent loss by death-Padre soltero, encarcelado 0 falleckio Child o is o was in foster care — E/nifo esta/ha estado con personas adoptivas 'b Prior or current CPS (chitd Protective Service) Involved Servicios de Proteccién infant) que partcipen Prior or current Head Start c VPI_o Special Education family member c Healthy Families — Un ‘hotmana‘a del nifio ha participado en el programa anteriormante o Substance abuse _o Substance addiction © Domestic violence (parent to parent, parent to, Child, child to child)~ Violencia doméstica Chronically il family member (physical, mental, emotional, ‘Substance abuseladdiction) Who? What? A/oune persona ‘rénicamonte enfornra en la familia (fsice, mental, emocional, abuso de sustancias/adiciones) Recent immigrantirefugee-From Inmigrante 0 refugiado recién ~ De: 1 Seasonal Migrant worker_trabajador migrante estacional Living Status (Hogar): c Ihave a Housing Choice Voucher- lent my home (,Aquilar?) a! own my home (gCompr6?) a Unstable housing alojamiento inestabie ‘9 Moved in with frionds/relatives vive con amigosfamilieres & Child has been abused (sexually, physically, or emotionally), - £7 nifo ha sido abusado (sexualmente, fsicamente © emocionalmente) J Moved 2 or more times in the last six months — Movi 2 0 mas tiempos en los iltimos sels meses Ts your child completely polly wained? (This Is NOT a requirement for Head Star!) :Su hijo usa e! bao solo completamente? (Esto NO os un requisito de Head Start) a Yes-c Sic No- No ‘3 Homeless — Sin casa 0 viviendo en residencia fempordinea 5 Parents completed level of education: Quo grado de fa escuela hee forminado dure papa los padkes? 9 Overcrowded housing algjamiento superpoblado Father Pac! Mother Mache: (Blam active Miltary Soy militar activo a lam a Veteran Soy un 0 Other = Otro veterang ‘understand this Ts an application ONLY and does not guarantee Services informed of any changes of adcress or phone number. | declare that Services si hay algun cambio de drsosiono Ge na ;nrollment in the program. Taso understand that MUST keep PR ave given complete, accurste, and Wuthfl information and certy that the ly ae accurate tothe best of my knowledge. 8 SOLAMENTE una aplicacion y no qarantiza matriculacion en el programa. Tambien enieno que NECESITO infornar a PK ro de telefono, Dactaro que he dado informacin completa, exacta y verazy cerfique que bs {Gocumentce y le informacion que he proparcionado acerca de la elegbilidad son exacts al mejor de mi conooimiento, Ciityou check this back you DO NOT went information shacad wih aber areschool programe. Marque no informacion a oto pre-escolar. ‘Where did you obtain this application? Cémo obtuvo usted esta aplicacién?. ‘Signature — Firma Date Fecha PC approval: Board approval Person Completing Application, If Assisted (03/3 1/22/EnrollmentApplication/English/SpanishShenandoah County Preschool Services Consent to Exchange Information J understand that different agencies provide different services. Each agency must have specific information in order to provide services, By signing this form, | am allowing agencies to exchange information so it will be easier for them to work together and to determine which services would be most beneficial and appropriate for me and my family. |, (parentiguardian) am signing this form for myself and the following person(s) for whom | am legally responsible: (preschoo! chil I want the following information to be available regarding the above named individuals: a, Assessment Information d, Financial Information b. Educational Records e, Benefit/Services Needed, Planned or Received . Medical Records Other, The following agencies will be allowed to exchange informati Shenandoah County Public Schools Shenandoah Memorial Hospital (Valley Health) ‘Skyline CAP Head Start/Early Start Shenandoah Department of Social Services Migrant Education Program Community Care & Learning Center/Mixed Delivery Grant PK SCPS ECE-Peer Pals Child Care Center: Infant Toddler Connection (ITC) Translator Healthy Families Response, Inc. Department of Rehabilitative Services/VEC Shenandoah Alliance for Shelter Shenandoah County Extension Office Shenandoah County Pregnancy Center Free CliniciWellness Center University of Virginia Shenandoah County Health Department Winchester Memorial Hospital (Valley Health) Moms In Motion/Precious Time Respite LFCC/NSVAE-Adult Ed/Workforce Job Center Family Promise Grandparents As Parents (G.A.P.) Physician: Northwestern Community Services Board Other: Strength In Peers | authorize Shenandoah County Preschool Services to share the information on this application with other early intervention programs that are available in my county, ensuring the best services for my child. | understand that this application does not ensure acceptance into any program. understand that | may withdraw this consent at any time by submitting a written note to that effect to the referring agency. This will stop the exchange of information after they know my consent has been ithdrawn. [have the right to know what information has been shared, If ask, each agency will show me this information. J want ail the agencies to accept a copy of this form as a valid consent to share information until child enters Kindergarten. Parent/Guardian Signature Date: 03/31/22 RevisedShenandoah County Preschool Services Consentir a Intereambiar Informacion Entiendo que diversas agencias proporcionan diversos servicios. Cada agencia debe tener informacién especifica para proporcionar servicios. Firmando esta forma, estoy permitiendo que las agencias intereambiaran la informacién as{ que seré més fitil que él trabaje junto y determinarse que servicios serian los ms beneficiosos y apropiados para mi y mi familia |, (padre/madre/tutor) que firma esta forma para me y el person(s) siguiente: para quién soy legalmente responsable. Quisiera que la informacién siguiente estuviera disponible mirando a los individuos arriba nombrados: a, Informacién del evaluacién 4. Informacién Financiera . Expedientes educativos e. Los Expedientes Médicos «. Asistencio /Los servicios necesitaron, planeado o recibieron Las agencias siguientes seran permitidas intercambiar la informacion: Departamento de la Salud del Condado De Shenandoah -Skyline CAP Head Start/Early Start -Las Escuelas Piblicas del Condado de Shenandoah -La Programa Educacién Migratoria -Departamento de los Servicios Sociales del Condado de Shenandoah, -Community Care & Learning Center/Mixed Delivery Grant PK -SCPS ECE-Peer Pals -Grandparents As Parents (G.A.P,) -Traductor -Centro Nifios Del Cuidado Del Dia: -Moms In Motion/Precious Time Respite “Healthy Families -Dept. of Rehabilitative Services/Virginia -Response, Inc. -Virginia Employment Commission -Shenandoah Alliance for Sheltet/Family Promise Shenandoah County Extension Office ~Shenandoah County Pregnancy Center -Free Clinie/Wellness Center -University of Virginia Infant Toddler Connection (ITC) -Médico: - LFCC/NSVAE-Adult Ed/Workforce Job Center -Shenandoah Memorial Hospital (Valley Health) -Winchester Memorial Hospital (Valley Health) -Otr0: -Sirength In Peers Autorizo servicios preescolares del condado de Shenandoah para compartir la informacion sobre este uso con otros programas tempranos de la intervencion que estén disponibles en mi condado, asegurar los mejores servicios para mi nifio. Entiendo que este uso no asegura la aceptacién en ningun programa. Entiendo que puedo retirar este consentimiento en cualquier momento sometiendo una nota escrita a ese efecto a la agencia que se refiere. Esto parara el intercambio de la informacion después de que sepan que mi consentimiento ha sido aislado. Tengo la derecha de saber se ha compartido qué informacién. Si pido, cada agencia me demostrard esta informacién. Quisiera que todas las agencias aceptaran una copia de esta forma como consentimiento valido para compartir la informacién hasta que el nifio entra en jardin de la infancia, **Birma de padre/madre/Tutor: Fecha: 03/31/22 Revised