Campbell County Schools Three and Four-Year-Old Pre-School Initiative
School Year
What school year are you applying for?
-
2024-2025
Child's Information
Child's name
First name:
Middle name:
Last name:
Current address of the child
Street Name:
Apt #:
City:
State:
-
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FM
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MH
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PW
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
AE
AA
AP
ZIP:
Child's birthday
Month:
-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day:
-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
-
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
What school are you zoned for?
-
Altavista Elementary School
Brookneal Elementary School
Concord Elementary School
Leesville Road Elementary School
Rustburg Elementary School
Tomahawk Elementary School
Yellow Branch Elementary School
Parent/Guardian's Information
Your name
First name:
Middle name:
Last name:
Your relationship to the child
-
Parent
Other
Grandparent
Guardian
Sibling
Step-Parent
Foster Parent
Great Grandparent
Relative
Self
Your phone number
Home/Cell #:
Work #:
Your email address
Family
Parent/Guardian's marital status
-
Single
Divorced
Married
Widow/Widower
Highest level of education of parents
Mother:
-
Not Required
No High School Diploma
GED
High School Diploma
Some College
Associates Degree
4 Year College Degree
Graduate Degree
Post Graduate Degree
Father:
-
Not Required
No High School Diploma
GED
High School Diploma
Some College
Associates Degree
4 Year College Degree
Graduate Degree
Post Graduate Degree
Is parent currently on military deployment?
-
Yes
No
Was mother or father a teen parent?
-
Yes
No
Is parent incarcerated?
-
Yes
No
Does the child live with relatives other than parents?
-
Yes
No
If yes, what is the relationship of the relative to the child?
-
Parent
Other
Grandparent
Guardian
Sibling
Step-Parent
Foster Parent
Great Grandparent
Relative
Self
Is the child in foster care?
-
Yes
No
Homelessness
Is the child's current address, listed above, considered a temporary living arrangement?
-
Yes
No
If yes, what is the reason for the temporary living arrangement?
Child's History
Does the child have an IEP (Individual Education Plan) for special education services?
-
Yes
No
If yes, what is the IEP for this child?
Please provide as much detail as possible.
Is English the child's second language?
-
Yes
No
If yes, what is the child's primary language?
-
Spanish
Korean
Chinese, Mandarin
Arabic
Vietnamese
Chinese
Finnish
Urdu
German
Other
Has the child been exposed to domestic violence?
-
Yes
No
Has the child been exposed to substance abuse?
-
Yes
No
Bus/Car Rider
Will your child need a bus to school next year?
-
Bus
I will provide transportation for my child
Click the Next button to continue to the next page.