Ready Region Southside Mixed Delivery Child Enrollment Form 2025

Ready Region Southside Mixed Delivery Child Enrollment Form 2025 - 2026
Ready Region Southside is partnering with private early childhood programs in our region to provide reduced-cost, high-quality early learning experiences for eligible families. This opportunity is part of Virginia’s Mixed Delivery initiative, a state-funded effort aimed at expanding access to early education across the Commonwealth.

The goal of this initiative is to help prepare children for success in kindergarten and beyond by ensuring they have access to strong early learning experiences.

Eligibility To qualify for tuition assistance through the Mixed Delivery initiative, families must meet specific financial need requirements set by Virginia Department of Education.

Please complete the information below to determine your child(ren)’s eligibility for tuition assistance. Note: This form does not replace your child care center’s registration packet. You must still submit the following documents directly to your child care provider:

• The center’s Registration Form
• Your child’s Immunization Record
• A School Entrance Physical Form
• Any additional documents required by your provider
CHILD INFORMATION
How many children are you enrolling?*
Child 1: Full Name: (Name MUST be as it appears on birth certificate)*

First NameM.I.Last Name
DOB:*

MonthDayYear
Date
Gender*
Ethnicity:*
Primary Language:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child 2: Full Name: (Name MUST be as it appears on birth certificate)*

First NameM.I.Last Name
DOB:*

MonthDayYear
Date
Gender*
Ethnicity:*
Primary Language:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child 3: Full Name: (Name MUST be as it appears on birth certificate)*

First NameM.I.Last Name
DOB:*

MonthDayYear
Date
Gender*
Ethnicity:*
Primary Language:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CHILD BACKGROUND INFORMATION
Child 1: Does your child have an identified disability?*

YesNo
Child 1: Please explain.*
Child 2: Does your child have an identified disability?*

YesNo
Child 2: Please explain.*
Child 3: Does your child have an identified disability?*

YesNo
Child 3: Please explain.*
Child 1: Does your child have an Individualized Education Plan (IEP)?*

YesNo
Child 2: Does your child have an Individualized Education Plan (IEP)?*

YesNo
Child 3: Does your child have an Individualized Education Plan (IEP)?*

YesNo
Are there any additional special needs?
Please list siblings living in the household and their ages: (Click save after adding each name. If no siblings please put N/A)*
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1:*

First NameM.I.Last Name
DOB:*

MonthDayYear
Date
Relationship to child:*
Ethnicity:*
Primary Language:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Mobile Phone*
Please enter a valid phone number.
Email*
example@example.com
Number of people living in the household:*
(Please include only persons that live in the household and parent/guardians that are financially responsible for the child)
Place of Employment (if not applicable please put N/A):*
Work Phone
Please enter a valid phone number.
If you are not currently employed, please explain Place of Employment (if not applicable please put N/A): :*
Parent/Guardian 2 (If not applicable please put N/A for first and last name. If adding parent/guardian please fill out all information for them):*

First NameM.I.Last Name
DOB:

MonthDayYear
Date
Relationship to child:
Ethnicity:
Primary Language:
Address (Complete ONLY if different than Parent/Guardian 1)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Place of Employment:
Work Phone
Please enter a valid phone number.
If you are not currently employed, please explain:
FAMILY INFORMATION
Have any of the following impacted your family in the last year (check all that apply):*

Loss of jobMedical billsFinancial hardshipIllnessHomelessness/loss of housingMental Health issuesIncarcerated parentAdverse childhood experiences or traumaEnglish as a second languageAt least one parent active or retired militaryNoneOther
Please explain financial hardship.*
Please check ALL the benefits you receive:*

Temporary Assistance for Needy Families (TANF)Supplemental Security Income (SSI)Supplemental Nutrition Assistance Program (SNAP)Women, Infants and Children (WIC)DSS Child Care Tuition Assistance (Subsidy)MedicaidUtility AssistanceNoneOther
Child 1: Is your child currently enrolled in a program?*

YesNo
Child 1: Please indicate the type of program*

Head StartVirginia Preschool InitiativeChild Day CenterFamily Day HomeOther
Child 1: Please provide name of program*
Child 2: Is your child currently enrolled in a program?*

YesNo
Child 2: Please indicate the type of program*

Head StartVirginia Preschool InitiativeChild Day CenterFamily Day HomeOther
Child 2: Please provide name of program*
Child 3: Is your child currently enrolled in a program?*

YesNo
Child 3: Please indicate the type of program*

Head StartVirginia Preschool InitiativeChild Day CenterFamily Day HomeOther
Child 3: Please provide name of program*
Child 1: Is your child currently on a waitlist for any other program?*

YesNo
Child 1: If yes, where is your child on a waitlist?*
Child 2: Is your child currently on a waitlist for any other program?*

YesNo
Child 2: If yes, where is your child on a waitlist?*
Child 3: . Is your child currently on a waitlist for any other program?*

YesNo
Child 3: If yes, where is your child on a waitlist?*
Use this space to provide any additional information you feel we need to know about your child and family:
Mixed Delivery Participation Agreement Mixed Delivery is a state-level initiative designed to expand access to early childhood education for children ages 0–5. For children ages 3 and 4, participation in the Virginia Kindergarten Readiness Program (VKRP) is required. To meet all Mixed Delivery program requirements, I agree to the following:
- If my child is 3 or 4 years old and participates in a preschool program, they will participate in state-wide assessments, including the Virginia Language and Literacy Screener (VALLS) and the Virginia Kindergarten Readiness Program (VKRP). I will receive a copy of the assessment results. This information will be stored in a secure database system.
- I understand that participation in periodic surveys is expected to help evaluate the impact of the Mixed Delivery initiative.
- I understand that consistent attendance is essential for ensuring the best experience and outcomes for my child. Failure to meet attendance expectations may result in the loss of my child's Mixed Delivery slot.
- I understand that if I am currently searching for employment, this status has a limit of 90 days, after which my situation will be re-evaluated.
- I certify that I have completed the Enrollment Form with true and accurate information.
Signature*

Clear
Date*

MonthDayYear
Date
Printed Name*
Relationship to child*
Should be Empty:

Ready Region Southside Mixed Delivery Child Enrollment Form 2025 - 2026

CHILD INFORMATION

CHILD BACKGROUND INFORMATION

PARENT/GUARDIAN INFORMATION

FAMILY INFORMATION