Preschool Notification Form

WAYNE COUNTY PUBLIC SCHOOLS PRESCHOOL DISABILITIES PROGRAM NOTIFICATION FORM

 

Child Name:  _____________________, _____________________ ________________

                       Last Name                                         First Name                                       Middle Name

 

DOB: ________________     Age: ______   Gender:    M      F       Ethnicity: _________

 

Current Setting: ______________________ ____________________  ______________

                            Name of childcare or Home               Address of childcare                               Phone Number

 

Medicaid:    Yes   No  Medicaid #: ________________      

                     Circle one

 

Parent/Guardian Name: ____________________________________________________

 

Parent/Guardian Address: __________________________________________________

 

Home Phone: ______________________  Phone (cell or work): ____________________

 

Referral Source: _______________________/____________________/___________________

                                    Person                                            Childcare/Parent/Other                     Agency or Source

 

Reason for referral: __________________________________________________________________

_________________________________________________________________________________

Previous evaluations completed. (Attach vision and hearing screenings and any other screenings or evaluations completed.)

_________________________________________________________________________________

 

 

Parent/Guardian: _______________________________      Date: ___________________

                                                                Signature

 

Parent has given permission for this information to be given to the Wayne County Public School Preschool Coordinating Committee for Child Find purposes. Wayne County Public School Preschool staff will contact you. If you have additional questions, please contact Rhonda Wiggins at (919) 705-2709 or Mary Ann McCabe-Jones at (919) 580-3578. Form can be faxed to (919) 580-3610 or mailed to Rhonda Wiggins Wayne Co. Preschool 801 N. Lionel St. Goldsboro, NC 27530

 

I am NOT interested in having Wayne County Public Schools Preschool Disabilities Program contact me regarding screening and possible educational services for my child:

 

Parent/Guardian: ______________________________        Date _________________________

                                                              Signature

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