Revised June 14, 2017
NCPre-K Application
Franklin County
The NC Pre-K Program is a program of the Division of Child Development and Early Education in the North Carolina Department of Health and Human Services. The NC Pre-K Program is designed to provide high-quality educational experiences to enhance school readiness for eligible four-year olds.
Instructions to complete application:
- Please complete one application for each eligible child.
- A child must be 4 years of age on or before August 31st to be eligible.
Please do not return application without:
- Copy of Birth Certificate
- Family Income Documentation (Check stubs representing one month, Tax Records, etc.)
- Signed Zero Income Statement when an individual claims to have no verifiable countable income. If one parent is not working, the income documentation of the working parent must be included and the other parent must complete the Zero Income Statement.
- Military Status Verification:Military Status must be verified via the Military Member’s Leave & Earnings Statement
It is required that the entire application be completed. Incomplete applications cannot be processed.
An application that does not include the documentation cannot be processed.
NC Pre-K Site Locations: Please select site preferences below by entering 1,2,3 on the blank lines.
Site Name / Select site preference by entering 1, 2, 3 on the blank lines.ABC Adventures
Children’s Ark
Dream World
Bunn Head Start
Nelson Head Start
Edward Best Elementary
Franklinton Elementary
Long Mill Elementary
Louisburg Elementary
*Please review the Letter to Parent tab on the web site for Application Processing Procedures.
Franklin County Schools’ applications are to be mailed to:
Dr. Stacy Stewart
NC Pre-K Application
Franklin County Schools
53 West River Road
Louisburg, NC 27549
ABC Adventures applications are to be mailed to:
ABC Adventures
118 Industrial Drive
Louisburg, NC 27549
Children’s Ark applications are to be mailed to:
Children’s Ark
404 South Cross Street
Youngsville, NC 27596
Dream World Academy applications are to be mailed to:
Dream World Academy
PO Box 714
Franklinton, NC 27525
Applications for Bunn Head Start and Nelson head Start are to be mailed to:
Head Start Director
PO Box 1453
Henderson, NC 27536
NC Pre-K Application
Franklin County
It is required that the entire application be completed. Incomplete applications cannot be processed.
Child’s Legal Name, Last: / First: / Middle:Date of Birth: / Was this child born in the U.S.A.? / Sex:
Male Female / Child’s Social Security Number: / Child’s Race:White
Black Hispanic Asian Indian
Child lives with: / Relationship to child:
Street Address: / How long have you lived at this address?
City: / State: / Zip Code: / County of residence:
Phone: Home Work Cell Message / Alternate Phone: Home Work Cell Message
Is the child currently in child care/day care/Head Start or any other Pre-K Program? No Yes / Did the child have difficulty adjusting to previous child care/day care/Head Start? No Yes, describe:______
Has the child previously been in child care/day care/Head Start or any other Pre-K Program? No Yes
If yes to the questions above, please list:
Name of Child Care Program(s)/ How long child has attended:
______/______
(see page 4 for additional space to add multiple programs)
What was the last date child attended child care program/location? ______. / Does the child have any serious illnesses or handicapping conditions?
No Yes, describe:______
Has the child had a formal developmental evaluation?
(Ex:. CDSA) No Yes
Child’s Health Status: (chooseone) / child has no significant health concerns / child is seen or being seen by a pediatric specialist for chronic health concerns / child is identified as mentally or physically chronically ill or medically fragile
Employment Status / Highest Level of Education / Language(s) Spoken
Mother’s Information:
Name: ______
Marital Status: Single Married Separated Divorced
Currently residing in the home with the child? Yes No / Employed Full-time
Where______
How long______
Employed Part-time
Where______
How long______
Unemployed
Disabled / Still in high school
Dropped out of school
GED
Some college
College Graduate
Level: AA BS MS / Check all that apply:
English
English as a 2nd Language
Spanish
Other:______
Father’s Information:
Name: ______
Marital Status: Single Married Separated Divorced
Currently residing in the home with the child? Yes No / Employed Full-time
Where______
How long______
Employed Part-time
Where______
How long______
Unemployed
Disabled / Still in high school
Dropped out of school
GED
Some college
College Graduate
Level: AA BS MS / Check all that apply:
English
English as a 2nd Language
Spanish
Other:______
Family Size (how many in actual family):
Write the three numbers below to determine Family Size.
Letter A:______
+Letter B:______
=Total Family Size:______/ A.
List adults (age 18 & over) residing in Child’s Household
(Parents and stepparents; legal guardianship (submit documentation if legal guardianship has been granted)
Name:
______
______
Has one or more parent been placed on a deployment list yes no / B.
Number of Children (under age 18) residing in Child’s Household: Include the NC Pre-K Child plus all minor brothers and sisters, half-brothers, half-sisters, stepbrothers and stepsisters.
Names and ages required to be listed.
Name: Age
1.______
2.______
3.______
4.______
5.______
6.______
7.______
8.______
9.______
10.______/ Gross Income of Child’s Actual Family:$______
Weekly
Monthly
Yearly
Parent/Guardian Acknowledgement
I understand by submitting this application that my child will be assessed for the North Carolina Pre-Kindergarten program. I understand if my child qualifies for the North Carolina Pre-K program, parent involvement will be critical to the success of my child. I/We will commit to participate as required by the criteria of the Pre-K program.
Assurance Statement:
I CERTIFY THAT I AM THE PARENT/GUARDIAN OF THE CHILD FOR WHOM THIS APPLICATION IS BEING MADE AND THAT ALL OF THE ABOVE INFORMATION IS TRUE AND CORRECT.
______
Signature: Parent/Legal Guardian (required) Date (required)
Franklin County
North Carolina Pre-K Program
Site Locations
ABC Adventures, Inc.Edward Best Elementary
118 Industrial Drive 4011 Highway 56 East
Louisburg, NC 27549 Louisburg, NC 27549
Site Administrator: Valerie Weston Site Administrator: Stephanie Brooks
Telephone: 919 496-2886 Telephone: 919 853-2347
Children’s Ark Franklinton Elementary
404 South Cross Street 431 South Hillsborough Street
Youngsville, NC 27596 Franklinton, NC 27525
Site Administrator: Jennifer Tippett Site Administrator: Melissa Richardson
Telephone: 919 556-7222 Telephone: 919 494-2479
Dream World Academy Long Mill Elementary
130 Savage Street1753 Long Mill Road
Franklinton, NC 27525 Youngsville, NC 27596
Site Administrator: Renee MuldrowSite Administrator: Dr. Monica Headen
Telephone: 919 494-2177 Telephone: 919 554-0667
Bunn Head StartLouisburg Elementary
750 Bunn Elementary Road50 Stone Southerland Road
Bunn, NC 27508Louisburg, NC 27549
Site Administrator: Naima MosleySite Administrator: Trenace Gilmore
Telephone: 919 496-0175Telephone: 919 496-3676
Nelson Head Start
102 Leonard Farm Road
Louisburg, NC 27549
Site Administrator: Naima Mosley
Telephone: 919 496-4585
Name of Child Care Program(s) (Previous Placement) How long did child attend?
1.______
2.______
3.______
4.______
5.______
Child placement in the NC Pre-K Program is contingent upon funding.
Zero Income Statement Certification
I, ______parent of ______,certify that I am unemployed and that I have no reportable income to determine for NC Pre-Kindergarten eligibility.
I understand that by submitting this statement that my child will be assessed for the North Carolina Pre-Kindergarten Program.
Assurance Statement:
I certify that I am the parent/guardian of the child for whom this statement is being made and that all of the above information is true and correct.
______
Signature : Parent/Legal Guardian (required) Date
Return this form with the NC Pre-K application if applicable.
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