<p> Mecklenburg County Public Schools Pre-School Application – 2012-2013</p><p>Mecklenburg County Public Schools offers a pre-school developmental program for at-risk four-year olds. This program provides a healthy learning environment that addresses the needs of the pre-school children who may be at-risk of poor school performance. The program is small due to funding and enrollment is competitive. All who apply will not be enrolled. Students must qualify for enrollment. Those who qualify, but are not enrolled, will be placed on a waiting list.</p><p>Please print legibly and fill in ALL information requested as it will be used to help determine eligibility.</p><p>Date: ______</p><p>Name of school community in which you live.  Chase City Elementary  Clarksville Elementary  LaCrosse Elementary  South Hill Elementary</p><p>Is your child attending school at present? ______If so, where ______</p><p>Name of Student: ______ Male  Female (Last) (First) (Middle)</p><p>Race: _____ Date of Birth: ______Birthplace: ______</p><p>Social Security Number: ______Birth Certificate Number: ______(No hospital identification numbers) Mailing Address: ______</p><p>911 Address ______</p><p>______</p><p>What school bus passes your home? Bus Number: ______</p><p>Father’s Name: ______Address: ______Highest Grade Completed: ______Place of Employment: ______Home Phone: ______Business Phone: ______</p><p>Mother’s Name: ______Address: ______Highest Grade Completed: ______Place of Employment: ______Home Phone: ______Business Phone: ______</p><p> Parents Living Together  Parents Not Living Together</p><p>Student Lives With (if other than parent(s):</p><p>Name: ______Relationship: ______Address: ______Phone Number: ______Are you receiving assistance from Social Services?  Yes  No If so, what? ______</p><p>Parent/Guardian resident of Mecklenburg County?  Yes  No</p><p>Please list all persons living in the home. Name Age Relationship ______</p><p>Comments: ______</p><p>Signature of Parent/Guardian completing this form: ______</p><p>FOR OFFICE USE ONLY</p><p>Signature of school representative who received this application: ______</p><p>Date Application Received: ______Complete information received:</p><p> Social Security Card #  Current Immunization Record</p><p> Birth Certificate #  Physical Examination</p><p>Comments: ______Mecklenburg County Public Schools P. O. Box 190 Boydton, Virginia 23917</p><p>Phone: (434) 738-6111, 447-7631, 374-8517 Fax: (434) 738-6650</p><p>School Phone Numbers: Chase City: 372-4770 Clarksville: 374-8668, LaCrosse: 757-7374 and South Hill: 447-8134</p><p>PRE-SCHOOL DEVELOPMENTAL PROGRAM</p><p>Program Overview: During the 2012-2013 school, Mecklenburg County Public Schools will operate a pre-school developmental program for children who will be four years of age on or before September 30, 2012. This program is designed to provide pre-kindergarten experiences for four-year olds and parents with strategies to help meet the educational needs of their children. Acceptance into this program will be contingent on results of a pre-school screening to be conducted in late Spring, 2012.</p><p>Classes will operate on the Mecklenburg County Public Schools’ 2012-2013 school calendar.</p><p>Requirements for Entry:  4 years old on or before September 30, 2012  Legal resident of Mecklenburg County  Documentation of immunizations - a minimum of three DTPs (diphtheria, tetanus and pertussis) with one administered after the fourth birthday</p><p>- a minimum of three OPVs (oral polio vaccine) with one administered after the fourth birthday</p><p>- one MMR (measles, mumps and rubella) received on or after the first birthday  Social Security Card  Birth Certificate  Physical Examination If you wish to have your child considered for this program, please complete the attached application form and return it to the school no later than, March 30, 2012. </p>