Apply Online

Thank you for your interest in our regional Childcare and Preschool Programs, including; Botetourt, Craig, Franklin, and Roanoke Counties; and the Cities of Roanoke and Salem. This application will help to match you with programs that you may be eligible for, as well as those that meet the individual needs of your family. Information collected can assist in determining your family’s eligibility for the following programs: Head Start, Virginia Preschool Initiative, Private Childcare, Family Day Home Provider, or additional state and federal assistance. In order to effectively process your application, you must provide information for all questions asked. Not answering all questions, or not providing required documentation, could cause a delay in determining your family’s status. Once your application has been processed and reviewed, your family will be contacted with information regarding next steps for you to take. Should you be placed on the waitlist for your program of preference, an alternative program will be provided to you in the form of a referral. You will be redirected to documentation uploads, eligibility questions, and location preferences when you submit this application.

Please complete the following information about the parent/guardian(s) of the child applicant.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Email Address (Required)

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Home Phone

Work Phone

Ext.

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

Click here to find a provider in your area.

Mailing Address same as Living Address

Mailing Address

Address Line 2

City

State

ZIP

Please, only include adults that are legally considered parent/guardian to the child applicant. This can be through biological relationship, marriage, or adoption. Any other adults contributing to the household may be added in "Other Adults". Appropriate paperwork such as custody papers shall be attached if parent is not allowed to pick up the child. *NOTE: Section 22.1-4.3 of the code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center must be included, upon , as an emergency contact for events occurring during school or day care activities.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Email Address

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Home Phone

Work Phone

Ext.

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Are there other adults in the household?

Add Another Adult

The following section is required to be completed in it's entirety if you would like to enroll your child in a free or reduced early education program or childcare center. Documentation is required to verify the following information. If your child is in foster care or homeless, and you are ONLY applying for Head Start, you may skip this section.

Number of Parents/Guardians

Primary Language at Home

Number in Household

Number in Family

Gross Annual Income

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

WIC ID (if applicable)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

Add Emergency Contact

Please complete the following information about your child.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

Dentist/Dental Home

Does your child have a disability or do you have any concerns about your child's development?

Is there anything else you want to tell us about your child?

Which program are you applying for? (Required)

1st Location Preference

2nd Location Preference

- Your Address - Available Locations

Click a location on the map to see more info

Click here to find a provider in your area.

Do you want to apply now for another child in your family?

Add Another Applicant

Are there other children in the family?

Add a Sibling

Once you submit, you will be redirected to the second portion of the application. This part of the application will allow you to choose location preferences, upload required documentation, and answer questions to determine eligibility. Thank you for taking the time to fill out our online application. We look forward to reviewing your information, and getting back to you soon.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings