Application

Registration/Application for Culpeper County Schools and Head Start

To All Preschool Applicants: The public preschool programs in this area are working together to provide quality preschool services to children in Culpeper County. The following application can be used to apply to the Culpeper County Public Schools’ preschool programs, and/or Head Start. Your application will be sent to the program in which your child qualifies. Space is limited in the preschool programs, and once classes are filled, those who do not get in will be placed on a Waiting List.

Eligibility for the preschool programs will be based on identified needs, which may include: income, academic needs, language deficiencies, special needs, and age. Bus transportation may be offered for four year olds. Parent involvement is important to preschool success and parents are encouraged to volunteer. If your child is accepted into any of the preschool programs, you will be required to fill out additional paperwork. If accepted into Head Start, a teacher will contact you to schedule a Home Visit.

Please complete the following application. We look forward to working with your child.

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1
Child's Namefull name
Date of Birthmm/dd/yyyy
Sex
Addressinclude ZIP
0 /
Elementary School District
Child lives with
If other, explain
0 /
Parent/Guardian Information
Mother's Nameparent/guardian
Date of Birthmm/dd/yyyy
Addressif different from the child
0 /
Home Phonemother
Work Phonemother
Cell Phonemother
Mother's Employer
Highest Level of Education Completedmother
Father's Nameparent/guardian
Date of Birthmm/dd/yyyy
Addressif different from the child
0 /
Home Phonefather
Work Phonefather
Cell Phonefather
Father's Employer
Highest Level of Education Completedfather
Personal Information
Does your child have an IEP (Individualized Education Plan) with the school system?
Does your child have a physical disability?
Does your child speak English?
Does the parent/guardian have any serious health related needs?
Do you have a Social Worker or Public Heath Nurse?
Have any of your other children been enrolled in preschool?
If Yes, name of school?
Are you presently receivingselect all that apply
Household Residenceselect all that apply
If Other, explain
0 /

Household Profile

Please list all individuals who live in the home–including the child, child's parent(s)/guardian, siblings, and other individuals living in the home.

Parents' Annual Income
Others in HouseholdList names, date of birth, relationship to child, and income if applicable
0 /
Signaturefull name of person filling out application
Today's Date
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1401 Old Fredericksburg Rd
Culpeper, VA 22701

540 829-2330

540 829-2057

reception@culpeperhumanservices.org

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