Pre-K Supplemental Questionnaire
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Email *
Child's first name *
Child's last name *
First Parent's/Guardian's first and last name *
Second Parent's/Guardian's first and last name
Current Virginia Beach street address *
Current Virginia Beach zip code *
Family type (check all that apply) *
Required
Marital status (check all that apply) *
Required
Total yearly income for family *
(include income for anyone working, SSI, disability, child support, unemployment benefits, rental income, trust fund, etc.)
How many people are in the household? *
(This would include those considered dependents.)
Is the child currently in foster care? *
Is the family lacking fixed, regular or adequate housing? *
(Considered homeless?)
Is there a chronic illness of a family member in the household? *
Has the child been abused? *
Yes
No
Physically abused
Sexually abused
Does a parent have substance abuse issues? *
Yes
No
Parent 1
Parent 2
Has the child witnessed or encountered trauma? *
Has a parent ever been incarcerated? *
Yes
No
Parent 1
Parent 2
Was either parent 19 years of age or younger at the birth of her/his first child? *
Yes
No
Parent 1
Parent 2
Does the family and/or child have limited English proficiency? *
Yes
No
Family
Child
Is either parent active duty military and been separated from the child during his/her lifetime? *
Yes
No
Parent 1
Parent 2
Is the child fully toilet trained? *
(does not wear a pull-up)
Does the child have an IEP plan for special needs? *
What level of education does the mother have? *
What level of education does the father have? *
What school is your home school? *
(the school zoned for your street address)
Phone number? *
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