·PreK/Virginia Preschoollnitiative(VPI) ProgramCovington City Public Schools

TheVPI program was created in 1994 by the General Assembly of Virginia to reduce disparities amongchildren upon formal school entry, and to reduce or eliminate those risk factors that lead to earlyacademic failure. State funding is available to serve at-risk four-year-olds who are not being served byHeadStart.

Eachyear the funding for the Virginia Preschool Initiative Program is determined by the State LegislativeBudget. Once the school division has been notified of funding, all applications received to that date willbe processedand families will be informed of the status of their application.

Covington City accepts applications for students who are or will be four years old by September 30 ofthe current school year. Acceptance to the program depends on screening and family factors suchasincome. Initial application review is from March 15 to May 15 for the following school year.Applications are accepted year round and eligible students may be selected off the wait list asspotsopen up.

In order to process the application, you must provide information for all questions askedon thedocuments. NQtanswering all questions could causea delay in determining the family's status for theprogram. More questions may be askedon the day of your child's screening.

Eligibility for PreK/VPI Program

• Child must be four years of age by September 30, 2020.

To be eligible for the program, a child must meet the following requirements:

• Eachchild must complete a preschool screening for Covington City Public Schools.

• Covington City residency is required and verification of residency must be provided. If a familymoves outside of Covington City limits during the school year, the child will no longer be eligiblefor PreKservices.

• A certified birth certificate issued from the Department of Vital Recordsmust be provided.

• A record of preschool immunizations must be provided along with a preschool physical.

• Documentation verifying family income (2019 Federal Income Tax Return or W-2s) must beprovided.

Covington City Public Schoolswill notify parents/guardians of the date and location for their child'sscreening. All documents for eligible children must be on file by June 15, 2020. Sincea limited numberof children may attend a program, applications for children who are eligible and not enrolled will beplaced on awaiting list.

Covington City Public SchoolsStudent Registration Information 2020-2021

Teacher: -.~------School: -------------------------

7/19

Please answer all questions. Please print with a pen. If any of your information changes during the year, pleasecall the school office or send a note to school to update information. Thank you.

Student Name MaieD FemaleD Grade--------------------------------------__-----------(last) (first) (middle)

Mailing Address City State_ Zip __

Phone / Social Security # Date of Birth _

Residence D Covington Resident D Alleghany Resident D Other -----------------------Parent/Guardian Info Parent # 1 Parent #2Parent Guardian NameHome addressHome NumberEmployer

Work NumberCelllPager NumberE-Mail addressIa # to callduring schoolhoursMilitary Information Active Duty: DYes DNo Active Duty: DYes DNo

National Guard or Reserves: DYes DNo National Guard or Reserves: DYes DNo

Names of brothers/sisters Age Grade Resideinsamehomeasstudent?YesorNo.

Emergency Contact List persons authorized to pick up your child from school and/or may be contacted in case ofillness or emergency. School staff will attelTlJltto contact the...Q.arent£guardianfirst.Name Relationshl2_ Phone

Please list individuals who are NOT AUTHORIZED (but may attempt) to pick up your child.

Special Services Received at Previous School 0 Special Education 0 504 Plan OSpeechDGiftediTalented OReadin 0 Title I DEn lish as a Second Lan ua e

Medical InformationPhysician Name Telephone # --., __Health Alerts and information (ex.: diabetes, allergic reactions, etc.) _

Your child has the following health insurance circle all that a I : Private Medicaid FAMIS None

Custody Information Complete only if parents are separated or divorced. Custody arrangements (check one):o Joint legal & physical 0 Joint legal with physical custody retained by: 0Mother 0 FatherD Sole legal & physical custody 0 No formal custody arrangements 0 Lives independentlyProvide allleaal documents re ardina custody & visitation.

--------------------------------------------------~

Covington City Public Schools - Student Registration Information 2020-2021 (page 2)

Birth Information Ethnicity (Choose only one) Race (must chooseat least one, maychooseoneormore; see information belowfor racedefinitions)

Birth City: DNo, not Hispanic or Latino DAmerican Indian or Alaska NativeDAsian

Birth State: DYes, Hispanic or Latino DBlack or African AmericanApersonofCuban,Mexican,PuertoRican, DNative Hawaiian/Other Pacific IslanderBirth Country: SouthorCentralAmerican,orotherSpanish DWhiteCultureor origin,regardlessof race.

Race Definitions:American Indian or Alaska Native: A person having origins in any of the original peoples of North and South American, including CentralAmerican, and who maintains tribal affiliation or community attachment.Asian: A person having origins in any of the original peoples of the Far east, Southeast Asia, or the Indian subcontinent including, forexample, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.Black or African American: A person having origins in any of the black racial groups of AfricaNative Hawaiian/Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other PacificIslandsWhite: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Home Language SurveyWhat date did the student enter School the United States? Month Date YearWhat is the primary language used in the home, regardless of the language spoken by the student? _What is the language most often spoken by the student?What is the language that the student first acquired? _What language(s) do adults speak at home? _Has the student ever received ESL (English as a Second Language) services? yes __ no __ maybe

Living Situation Complete only if student lives in any of the below locations/situations. Check the appropriate box.Dshelter Dmotellh6tel, campground or similar setting Dcar D public building or spaceDawaitin foster care Dlivin with another famil due to loss ofhousin or economic hardshi

Previous School History: Has student previously attended Covington City Schools? DYesMost recent school attended if other than Covington City Public Schools:School Name Address ---------------------------Ending date of attendance _

o No

Transportation How will your child get to and from school each day?School bus D a.m. D p.m. Car D a.m. D p.m. Walk D a.m. D p.m.AM bus pick-Up; specific street addressPM bus drop-o ff; specific street address _

Parent/Guardian Signature Date

REGISTRATION FORM STATEMENT

Ihereby swear and affirm that the student named on the front of this form has not been expelled from schoolattendance at a private school or in a public school division of the Commonwealth or another state for an offense orviolation of school board policies relating to weapons, alcohol or drugs, or for the willful infliction of injury toanother person. Iunderstand that any person making a materially false statement or affirmation shall be guilty uponconviction of a Class 3 misdemeanor.

, 03/20/18

Covington City Public SchoolsPreschool Programs

APPLICATION FORMSchool Year 2020-2021

All information listed will be kept strictly confidential.Child's Information:Child's Name: First Middle Last, _Nickname: Male Female Social Security Number: _Street Address: City: Zip: _

Do you plan to move prior to the first day of school in August, 2019? Yes NoIfye~pleaseli~yournewaddress: _

Date of Birth: Age: Primary Language: _

Asian/Pacific Islander Hawaiian Black (Non-Hispanic)Other

Ethnicity: American Indian/AlaskanWhite (Non-Hispanic)

Hispanic

Current Preschool or Child Care Center (if enrolled): _

Is your child toilet trained? Yes NoDoes your child have a disability or special need? Yes NoIf yes, what is the disability or special need? _If yes, where does your child receive services? _(All programs accept children with disabilities or special needs. Children will be referred to CCPS appropriate special educationprograms.)Do you have concerns about your child's development or behavior? Yes NoIf yes, please describe your concerns: _

Parent/Guardian Information:Mother/Guardian's Name: Father/Guardian's Name:

Address: Address:

Home Phone: Home Phone:Work Phone: Work Phone:Cell Phone: Cell Phone:E-mail: E-mail:Date of Birth: Date of Birth:Are you employed? Yes No Salary: Are you employed? Yes No Salary:Where employed? Hours per Where employed? Hours perweek-- week--Proof of income, including TANFor DSSassistance must be provided Proof of income, including TANFor DSSassistancemust be providedfor Head Start and Covington Preschool Programs for Head Start and Covington Preschool ProgramsLast grade completed by mother: ___ Last grade completed by father: ___

Program Selection:Please consider my child for the following program(s) that I have circled. I understand that there are limited spaces available in allprograms and these programs have guidelines and application processes required for program entry.Circle: Covington City Public Schools preschool program for 4 year olds /Virginia Preschool Initiative Program

Early Childhood Special Education ProgramInclusion Program with Early Childhood Special Education (IPOP) for 3 and 4 year olds

If your child is not eligible for the program you selected, do you wish to be considered for another program listed? yes noWill you obtain child care before/after the preschool program your child attends? yes no unsureIf yes, please list name and location: _

(continued on back)

1FAMILY FACTORS

The information on this form is used to determine eligibilityand to address family needs. CovingtonCityPublicSchools does not unlawfullydiscriminate on the basis of sex, race, color,age, religion, disabilities,or national origin in employment or in its educational programs or activities.

Household Information:Child's Name: ----:-Person completing this form: Relationship to child: _Who has legal custody of child? _Child liveswith One Parent Two Parents Foster Parents Other/Guardian (please specifv) --Brothers and sisters in household under 18 year of age:Full Name: Age: school/Preschool/Child CareCenter:

Family Factors- Pleasecheck all that apply:Child is receiving :(circle) Medicaid FAMIS WICFamily is receiving food stampsChild has no health insuranceFamily receives TANF-Temporary AssistanceFor Needy Families (documentation required)Child has a diagnosed disabilityChild has chronic illness (such as diabetes, asthma, etc.)Child was born prematurelyihigh risk pregnancyChild is in foster careChild was in foster careChild was in an orphanageChild or family is in counselingTeen mother or father at time of child's birth

Deceased parentSingle parent familyParent deployed in militaryParent has a diagnosed disabilityParent has a mental illnessChronic or terminal illness in familySubstance abuse in the householdDomestic violence in the homeFamily uses English as a second languageParent/Guardian did not complete high school or receive aGEDFamily rents/leases home/apt.Family Owns homeA family member was diagnosed with learning

Incarcerated parent(s) problems or difficulty reading and required specializedHomeless family (living inlwith: street, car, shelter, interventionshotel, friends/relatives)

Is there anything else you would like us to know about your child or family? _

Upon acceptance in a CCPS preschool program, the following four documents are required immediately:*Birth Certificate *Current Physical Examination *Current Immunization Record *Proof of Residency

I certify that everything above is correct, to the best of my knowledge. I understand that Covington City Public Schools andall Preschool Programs work in partnership and all information will be kept strictly confidential. I give permission for therelease of information regarding my child's screening, eligibility, and enrollment between Covington City Public Schools andall Preschool Programs.

Signature of Parenti Guardian: Date: _

Additional Notes/Information: _

For Office Use Only: Age Verified: (list age): _Application Received: Date: Location: Staff Name: _Covington City School Employee? Yes NoApplication Sent to Head StartlCCPS: Date: Receiving Staff Name: _Student Information: Program Placement: Enrollment Date: _Evaluator's Recommendation/Comments (be specific): _

VIRGINIA PRESCHOOL INITIATIVEPARENT QUESTIONNAIRE

2020-2021

STUDENT NAME: __

PARENT NAME: _

Please answer the questions which are required by the Virginia General Assembly for thoseschool divisions who participate and receive funding for the Virginia Preschool Initiative. Youranswers are kept in a confidential manner. Please answer by circling yes or no and place back inenvelope. Thanks for your assistance.

1) Single parent household? Yes No

2) One or both family members under the age of 21 ? Yes No

3) A parent has less than a 12th grade education? Yes No

4) A parent has less than an 8th grade education? Yes No

5) A parent received special services while in public school (specialeducation, speech, Title I)? Yes No

6) A parent cannot read? Yes No

7) Child is currently in foster care? Yes No

8) Child has been involved with Social Services due to abuse or neglect issues? Yes No

9) A parent has a drug or alcohol problem? Yes No

10)A parent is injail? Yes No

11) Family receives public assistance (TANFIFood Stamps) Yes No

12) Child is eligible for Medicaid? Yes No

13) A parent is unemployed? Yes No

14) Your family is homeless? Yes No

15) Child has health problems? Yes NoIf yes, please explain:

16)Child has developmental problems due to problems caused at birth?(such as a premature birth)If yes, please explain: _

Yes No

,COVINGTON CITY PUBLIC SCHOOLS

VPIPROGRAMRESIDENCE VERIFICATION FORM 2020-2021

Student: __

Parent/Guardian: _

Address: _

Student DOB: Phone:

Attached is appropriate documentation that our family resides at this Covington City address.(See attached documentation).

Parent/Guardian Signature Date

Note:

If your family should move to a new Covington address during the school year, please providethe new address immediately to school staff.

In addition, should you move to a residence outside the Covington City limits, your child wouldno longer be eligible to participate in the VPI/PreK program.

.t

COVINGTON CITY PUBLIC SCHOOLS

VPIPROGRAMFAMILY FINANCIAL VERIFICATION FORM 2020-2021

Student: _

Parent/Guardian: _

Address: _

Student DOB: _ Phone: ------------

I verify that the attached appropriate financial information (W2s from last tax return and payrolldocuments) is verification of my family's annual income. (attach appropriate documentation)

Parent/Guardian Signature Date

City Staff Verification:

Family annual income falls at the poverty level below based on family verified documentation:

_______________ _..:..c%::_povertylevel

COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORM

Health Information Form/Comprehensive Physical Examination Report/Certification of Immunization

State law (Ref. Code of Virginia § 22.1-270) requires that your child is immunized and receives a comprehensive physical examination before entering publickindergarten or elementary school. The parent or guardian completes this page (Part I) of the form. The Medical Provider completes Part II and Part III of theform. This form must be completed no longer than one year before your child's entry into school.

Part 1- HEALTH INFORMATION FORM

Name of School: Current Grade: ----------

Student's Name -,- -:::c:-- --,-:-:-:-- _Last First Middle

Student's Date of Birth: __ 1__ 1___ Sex: State or Country of Birth: Main Language Spoken: ------

Student's Address: City: State: Zip: ------

Name of Parent or Legal Guardian I: Phone: Work or Cell: -- ----

Name of Parent or Legal Guardian 2: _

Emergency Contact: Phone: --- --- ----

Phone: _ Work or Cell: _

Work or Cell: _

Condition Yes Comments Condition Yes Comments

Allergies (food, insects, drugs, latex) Diabetes

Allergies (seasonal) Head injury, concussions

Asthma or breathing problems Hearing problems or deafness

Attention-Deficit/Hyperactivity Disorder Heart problems

Behavioral problemsLead poisoning

Developmental problems Muscle problems

Bladder problem Seizures

Bleeding problemSickle Cell Disease (not trait)

Bowel problemSpeech problems

Cerebral PalsySpinal injury

Cystic fibrosisSurgery

Dental problemsVision problems

Describe any other important health-related infonnation about your child (for example; feeding tube, hospitalizations, oxygen support, hearing aid, dental appliance,etc.).: _

Signature of Parent or Legal Guardian: Date:

List all prescription, over-the-counter, and herbal medications your child takes regularly:

Check here if you want to discuss confidential information with the school nurse or other school authority. 0Yes 0No

Please provide the following information:

Name Phone Date of Last Appointment

Pediatricianlprimary care provider

Specialist

Dentist

Case Worker (if applicable)

Child's Health Insurance: None __ FAMIS Plus (Medicaid) FAMIS __ PrivatelCommerciallEmployer sponsored

I, (do__) (do not__) authorize my child's health care provider and designated provider of health care in theschool setting to discuss my child's henlth concerns and/or exchange information pertaining to this form. This authorization will be in place lintil or unless youwithdraw it. YOlllllay withdraw your numorttntion at an)' time by contacting your child's school. When information is released from yallr child's record.docllmelltation of the disclosure is maintained in )'ollr child's health or scholastic record.

Signature of person completing this form: Date ---,----,-----

Signature of Interpreter: Date: ---I I-----

MCH 213G reviewed 03/20t4

COMMONWEALTH OF VIRGINIASCHOOL ENTRANCE HEALTH FORM

Part II - Certification oflmmunization

Section ITo be completed by a physician or his designee, registered nurse, or health department official.

See Section II for conditional enrollment and exemptions.

A copy of the immunization record signed or stamped by a physician or designee, registered nurse, or health departmentofficial indicating the dates of administration including month, day, and year of the required vaccines shall be acceptablein lieu of recording these dates on this form as long as the record is attached to this form.Only vaccines marked with an asterisk are currently required for school entry. Form must be signed and dated by theMedical Provider or Health Department Official in the appropriate box.

/.OSI

Student's Name Date of Birth: LI _-L-~,--_IMiddle Mo. Yr.Firsl

IMMUNIZA nON

2 3 4 5'Diphtheria, Tetanus, Pertussis (DTP, DTaP)

(given after 7

RECORD COMPLETE DATES (month, day, year) OF VACCINE DOSES GIVEN

52 3 4

"Poliomyelitis (IPV, OPV)

'Haemophilus inlluenzae Type b(Hib conjugate)

for children <60 months of'Pneumococcal (PCV conjugate)'only for children <60 months of age

Measles, Mumps, Rubella (MMR vaccine)

'Measles (Rubeola)

"Mumps

'Hepatitis B Vaccine (HBV)o Merck adult formulation used

"Varicella Vaccine

Hepatitis A Vaccine

Meningococcal Vaccine

Human Papillomavirus Vaccine

Other

Other 2 53 4

I certify that this child is ADEQUATELY OR AGE APPROPRIATELY IMMUNIZED in accordance with the MINIMUM requirements for attending school, childcare or preschool prescribed by the State Board of Health's Regulationsforthe Immunizationof SchoolChildren(Reference Section Ill).

Signature of Medical Provider or Health Department Official: Date tMo., Day, Yr.):_'_' __

MCH 213G reviewed 0312014 2

Student's Name Date of Birth: L_L_L_I

Section IIConditional Enrol/ment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

MEDICAL EXEMPTION: As specified in the Codeof Virginia§ 22.1·271.2, C (ii), I certify that administration of the vaccine(s) designated below would bedetrimental to this student's health. The vaccine(s) is (are) specifically contraindicated because (please specify):

DTP/DTaPffdap:[_}; DTffd:[_}; OPVIJPV:[_}; Hib:[_}; Pneum:[_}; Measles:[_); Rubella:[_}; Mumps:[_}; HBV:[_}; Varicella:[_}

This contraindication is permanent: [_], or temporary [_) and expected to preclude immunizations until: Date (Mo., Day, Yr.):LLU.Signature of Medical Provider or Health Department Official: Date (Mo., DIlY,Yr.):I_LLI

RELIG 10US EXEMPTION: The Code of Virginiaallows a child an exemption from receiving immunizations required for school attendance if the student or thestudent's parent/guardian submits an affidavit to the school's admitting official stating that the administration of immunizing agents conflicts with the student's religioustenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE- I), which may be obtained atany local health department, school division superintendent's office or local department of social services. Ref. Codeof Virginia§ 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia§22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccinesrequired by the State Board of Health for attending school and that this child has a plan for the completion ofhislher requirements within the next 90 calendar days. Nextimmunization due on ~-_

Signature of Medical Provider or Health Department Official: Date (Mo., Day, Yr.):LLLI

Section IIIRequirements

For Minimum Immunization Requirements for Entry into School andDay Care, consult the Division of Immunization web site at

http://www.vdh.virginia.gov/epidemiology/immunization

Children shall be immunized in accordance with the Immunization Schedule developed and published bythe Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), theAmerican Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),

otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a).(Requirements are subject to change.)

Certification of Immunization 03/2014

MCH 213G reviewed 03120143

Part III -- COMPREHENSIVE PHYSICAL EXAMINATION REPORT

\ qualified licensed physician, nurse practitioner, or physician assistant must complete Part Ill. The exam must be done no longer than one year before entrynro kindergarten or elementary school (Ref Code of Virginia § 22.1-270). Instructions for completing this form can be found at www.vahealth.orgtschoolhealth.

't I r's Name: Date of Birth: Sex: D M 0 F) Ul en .

Physical EX8mination

Date of Assessment: I I 1 = Within normal 2 = Abnormal finding 3 = Referred for evaluation or treatment-------

\

Weight: lbs. Height ___ ft. --- in. I 2 3 1 2 3 I 2 3

- Body Mass Index (BMI): BPc: HEENT Neurological Skin.. n 0 0 0 0 0 0 0 0

E 0 Age / gtlluef appropriate history completed'" Lungs Abdomen Genital'" 0 0 0 0 0 0 0 0 0.. 0 Anticipatory guidance provided'"'"< Heart 0 0 0 Extremities 0 0 0 Urinary 0 0 0

'5 TB Screening: 0 No risk for TB infection identified o No symptoms compatible with active TB disease'"OJ o Risk for TB infection or symptoms identified::t Test for TB Infection: TST IGRA Date: TST Reading __ mm TST/IGRA Result: 0 Positive o Negative

CXR required if positive test for TB infection or TB symptoms. CXR Date: o Normal 0 Abnormal

EPSDT Screens Required for Head Start - include specific results and date:Blood Lead: HctlHgb

Assesseiror: Assessment Method: Withinnormal Concern identified: Referredfor Evaluation

S EmotionallSocialc: Problem Solving'" cE ..Cot! Language/Communication0 '"QjCll

Fine Motor Skills;.OJQ

Gross Motor Skills

0 Screened at 20dB: Indicate Pass (P) or Refer (R) in each box.

.~~\ R t

1000 I 2000 I 4000

Io Referred to AudiologistlENT o Unable to test - needs rescreen

.. .. I1

o Permanent Hearing Loss Previously identified: Left _Right<"I .... -.. (J I L 1 ·1::tV) o Hearing aid or other assistive device

0 Screened by OAE (Otoacoustic Emissions): o Pass o Refer

o With Corrective Lenses (check if yes)Stereopsis 0 Pass 0 Fail I 0 Not tested I

c c Distance I Both IR TL I Test used: Io ..._ ..T 201'" .. I 201 I 201 I I;;~

o Pass o Referred to eye doctor o Unable to test - needs rescreen

o Problem Identified: Referred for treatment

o No Problem: Referred for prevention •

o No Referral: Already receiving dental care

Summary of Findings (check one):

:2 uo Well child; no conditions identified of concern to school program activities

:: c o Conditions identified that are important to schooling or physical activity (complete sections below and/or explain here):U c. ~....<> .. _ Allergy 0 food: o insect: a medicine: o other:..c e,v c: Type of allergic reaction: o anaphylaxis o local reaction Response required: o none o epinephrine auto-injector o other:rJJ 0

" '.c::.... c _Individualized Health Care Plan needed (e.g., asthma, diabetes, seizure disorder, severe allergy, etc)!::. ...

t::E ... _ Restricted Activity Specify:., ~c _ Developmental Evaluation o Has IEP o Further evaluation needed for:.g >.i:.. ..-0 W;l _ Medication. Child takes medicine for specific health condition(s). o Medication must be given andlor available at school.

c... ....E 0 _ Special Diet Specify:E oj0 ....v '" _ Special Needs Specify:... Ucz:

Other Comments:

Health Care Professional's Certification (Write legibly or stamp) o By checking this box, I certify with an electronic signature that all of

the information entered above is accurate (enter name and date on signat.;:e and date lines below).

Name: Signature: Date: _1__ 1_-

Practice/Clinic Name: Address:

Phone: - Fax: ------ - Email:-------

MCH 213G reviewed 0312014 4