Eligibility Screener Supports and Services

Eligibility Screener

Birth - 5 Supports and Services
This screener will help determine your eligibility for various programs such as Head Start, VPI, and Mixed Delivery. Many of our region's childcare funding programs are currently full and accepting children on waitlist status. Foundation First will utilize the information provided below to assess which childcare supports and services are most effective in helping children succeed in school and life. Please be assured that any reports generated will not include personal or identifiable information about you or your child(ren).
Parent/Guardian Contact Information
Parent Name*

First NameLast Name
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Household Information
Number of total household members *
How many children birth - 5 are you seeking childcare for?*
1 Child
2 Children
3 Children
4 Children
5 or more Children
Location of Childcare Services
What county are you seeking care in? (select all that apply)*

Caroline CountyCity of FredericksburgCulpeper CountyFauquier CountyKing George CountyLoudoun CountyManassas CityManassas ParkPrince William CountySpotsylvania CountyStafford County
Eligibility
Combined Gross Income*
The total income earned by all financially responsible individuals within a household before any taxes or deductions are applied. It typically includes wages, salaries, bonuses, rental income, investment income, child support, and any other sources of earnings.
Reported income in preceding question is on this schedule: *
Parent #1 Activity (check all that apply)

EmployedParticipating in a training program (school, GED class, ESL classes, vocational program, etc)Job searchNone of the above
Parent #2 Activity (check all that apply)

EmployedParticipating in a training program (school, GED class, ESL classes, vocational program, etc)Job searchSingle parent householdNone of the above
Eligibility Criteria (Check all that apply)*

Child is experiencing homelessnessChild has identified disability or receives early interventionChild is being evaluated for special education servicesChild receives Medicaid BenefitsChild receives SNAP (Supplemental Nutrition Assistance Program) BenefitsChild receives SSI (Supplemental Security Income)Child receives TANF (Temporary Assistance for Needy Families)Child receives WIC (Women, Infants, Children)A parent will be on military deployment during this school yearA parent was incarcerated during the past 5 yearsA parent did not graduate high schoolAbuse/trauma within the familyChild is an English Language LearnerChild is being cared for by a relative other than parentsChild is in foster careHigh risk pregnancy/premature birthNone of the above
Do you have concerns about your child's behavior/development (speech & language, learning delays)?*

YesNo
Acknowledgments
My initials below authorize the release of information to Early Childhood programs that you request, or are deemed eligible for. *
Questions or Comments:
I First Name* Last Name* acknowledge that this is an Eligibility Screener and is not an enrollment application nor does it guarantee my child(ren)'s placement into a program.
Signature*

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Eligibility Screener

Parent/Guardian Contact Information

Household Information

Location of Childcare Services

Eligibility

Acknowledgments