Integrated/Role Model Preschool Application
In an effort to make the best selection of students to be interviewed for the Integrated/Role Model Preschool Program the following questions have been compiled.

Before your child can be considered for an interview they must first meet these three requirements:

1. Resident of the city of Suffolk.
2. Be 3 years of age by September 3, 2020.
3. Complete and submit this application by 4:00 pm on Friday, April 3, 2020.

If your child is selected for enrollment, there will be no charge for your child’s participation in this program.
Child's Name *
First and Last
Your answer
Child's Current Age: *
Child's Date of Birth: *
MM
/
DD
/
YYYY
Parent/Guardian's Name(s) 1: *
Your answer
Home Address1: *
Your answer
Phone Number 1: *
(XXX) XXX - XXXX
Your answer
Additional Phone Number 1:
(XXX) XXX - XXXX
Your answer
Parent/Guardian's Place of Employment 1: *
Your answer
Work Phone Number 1:
(XXX) XXX - XXXX
Your answer
Parent/Guardian's Name(s) 2:
Your answer
Home Address2:
Your answer
Phone Number 2:
(XXX) XXX - XXXX
Your answer
Additional Phone Number 2:
(XXX) XXX - XXXX
Your answer
Work Phone Number 2:
(XXX) XXX - XXXX
Your answer
Parent/Guardian's Place of Employment 2:
Your answer
Current Daycare Arrangements: *
Name of Daycare or Babysitter
Your answer
Address of Current Daycare Arrangements: *
Your answer
Developmental and Social Milestones
This is a program to encourage developmental and social growth in preschoolers with delays. Below are a series of questions that will help give us an idea of YOUR CHILD'S level of development and social skills.
Check all that apply: *
Please check below ALL of the items that best describe your child.
Required
Please briefly describe your child's strengths and weaknesses. *
Your answer
How does your child indicate/communicate their wants and/or needs? *
Your answer
What opportunities does your child have to interact with other children? *
Your answer
What is their behavior during those interactions? *
Your answer
What does your child like to do? *
Your answer
Briefly describe your child's experience in daycare/preschool. *
Please note if this will be you child's first experience in a preschool setting.
Your answer
Why have you chosen to apply for the Integrated Preschool Program? *
Your answer
Has your child had any experience with children with disabilities? *
If yes, please explain.
Your answer
Preschool Selection *
Please select the most desired preschool site you would like your child to attend if chosen to participated in the Integrated/Role Model Preschool Program. (School one (1) will be your most desired and school five (5) should be your least desired.) Transportation will be provided for children attending a school within their preschool zone. If an out-of-zone preschool is selected transportation WILL BE THE PARENT'S RESPONSIBILITY. If you have questions about a preschool zone for your address, contact Krystal Reid (757) 925-6767. The preschool sites may change and additional sites may be added based on the needs of the early childhood special education needs.
Florence Bowser Elementary
Kilby Shores Elementary
Booker T. Washington Elementary
Northern Shores Elementary
Oakland
One (1)
Two (2)
Three (3)
Four (4)
Five (5)
Additional Information
Questions may be directed to Krystal Reid, Early Childhood Educational Diagnostician or Michele Mason, School Social Worker from the Early Childhood Resource Center at (757) 925-6767. All applications will be reviewed but NOT all who apply will be interviewed. If your child is selected for an interview, you will be contacted by a member of the staff from the Early Childhood Resource Center. Students who are selected for the Integrated/Role Model Preschool Program will follow the 2020 - 2021 school schedule for the elementary that they will attend. Students that are selected must attend school regularly.
Email Address: *
To receive correspondence via email (Interview request and/or meeting notices) and confirmation of receipt of your application please enter a valid email address.
Your answer
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