Mixed Delivery Eligibility Screener
Mixed Delivery is a grant that pays tuition to Virginia childcare programs, creating low- or no- cost childcare slots for families. We are currently on a waitlist for Mixed Delivery slots in our region and are requesting more grant financing from the state to enable us to add more slots. Slots will be filled by children on the waitlist as they become available. This information is kept confidential and is safely maintained. Your responses are used only to determine probable eligibility and create our Mixed Delivery waitlist. If you need assistance filling out this form, please ask your childcare director or email megan@foundationfirstva.org.
Child's Name (as it appears on birth certificate)
*
First Name
Last Name
Child's birthdate
*
-
Month
-
Day
Year
Date
Child's Zip Code
Is the child currently enrolled in any of the following programs
*
Please Select
Blue RibbonAcademy
Learn 'N Play Children's Center
Dawning Point - Kingsland Drive
Happy Hands (Ms Sheerley)
Sparks Adaptive Academy
Bilingual Childcare (Ms Yanira)
Not enrolled in any of the above programs
Please provide the name of the childcare program your child is or will be attending. If you are not sure which program, please provide the name of the county where you would like to enroll in a program.
*
What county will your child be enrolled in childcare?
Fredericksburg
Stafford
Prince William
Manassas Park
None of the above
Parent's Name
*
First Name
Last Name
Parent's Email
*
example@example.com
Parent's Phone Number
The following information is used to determine eligibility. Check all that apply
*
Child is experiencing homelessness
Child’s parents or guardians did not complete high school
Child has identified disability or receives early intervention or is being evaluated
A parent will be on military deployment during this school year
A parent was incarcerated during the past 5 years
Abuse/trauma within the family
A language other than English is spoken in the home
We receive WIC, SNAP, TANF, or Medicaid
Child is being cared for by a relative other than parents
Single parent household
None of the above
Parent #1 GROSS income (take amount before taxes/deductions are taken out and multiply it by how many times you get paid in the year)
*
Parent #1 reported income in preceding question is on this schedule:
Weekly
Monthly
Every 2 weeks
Twice per month
Other
Parent #2 GROSS income (take amount before taxes/deductions are taken out and multiply it by how many times you get paid in the year. If parent #2 does not support the child financially, type 0 in the box. If parent #2 provides child support, you can use this number instead of total income)
*
Number of people in household that are supported by the incomes listed above
*
Parent #1 activity requirement (check all that apply)
*
Employed
Participating in a training program (school, GED class, ESL classes, vocational program, etc)
Looking for a job
None of the above
Parent #2 reported income in preceding question is on this schedule:
Weekly
Monthly
Every 2 weeks
Twice per month
Other
No income
No Parent #2
Parent #2 activity requirement (check all that apply)
*
Employed
Participating in a training program (school, GED class, ESL classes, vocational program, etc)
Looking for a job
There is no Parent #2
None of the above
Other Notes
Name of person completing this form
*
First Name
Last Name
Email of person completing this form
example@example.com
Relationship to child (OR your title if you are a program director)
Today's Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: