2019-20 Head Start / Preschool Application Have you ever filled out - - PDF document

• M. Init.
• App. Date

Grade 9 or less Unemployed Grade 10 Some College/Vocational/ Self employed Job training or in school Grade 11 Associates Degree Employed seasonal GED Homemaker Retired or disabled Education Completion Date Phone Home: Mobile: Work: E-mail: City State Zip Code Other Address Parents (biological, step, adoptive) Other Relatives (nongrandparent) # in Family Other # in Household Specify: Public Ads (newspaper) Public Service Announcement (tv, radio) Race Pacific Island Languages Receives WIC Yes No Middle-Eastern Languages Native American Pacific Island Languages Other __________________ Other Flyers/Posters

(Select Only One)

Veteran of US Military Recruitment Activities: How did you hear about the Head Start program and our application process? Community Event Former HS Parent Agency Referral Family/Friend Foster Parent(s) (Active) US Military White Mailings Middle-Eastern Languages Spanish

Month / Day / Year

_ _ / _ _ / _ _ _ _ Current Housing Homeless Own Rent Other Ethnicity Unspecified Bi/Multi-racial Hispanic Yes No Previous Housing Rent Other Current Housing Start Date

2019-20 Head Start / Preschool Application

Enrolling Agency Enrolling Site Have you ever filled out a Head Start application? Yes No

Primary Caregiver General Information

Last Name First Name Gender Male Female B-Day Other __________________ Language English Pacific Islander Bachelor or Advanced Degree Spanish English Other Language Black If " Homeless " or " Other " is listed for Current Housing, you must complete a Family Residency Questionnaire High School Graduate Asian Employer / School Name Other____________ Homeless Own Medical Insurance Receives Food Stamps/SNAP Two Parent Single Parent Parent(s)/Guardian(s) Best Descriptor Grandparents Family Structure Education Level Employment Status Employed Full Time Employed part-time Home Address

Address Type:

Previous Mailing Other

• M. Init.

Retired or disabled Job training or in school Employed seasonal Self employed Unemployed Education Completion Date Phone Home: Mobile: Work: E-mail: City State Zip Code Specify: Primary: Secondary: Employment Status Spanish Gender Male Female B-Day Middle-Eastern Languages Unspecified Other __________________ Other Language Race White Other __________________ Spanish Middle-Eastern Languages Other____________ Native American Employed part time No Secondary Caregiver (skip application for secondary caregiver)

Secondary Caregiver General Information

First Name English Last Name Pacific Island Languages Language English Pacific Island Languages Ethnicity Bi/Multi-racial Bachelor or Advanced Degree Grade 11 Hispanic Asian Black Associates Degree GED High School Graduate Pacific Islander Education Level Grade 10 Employed full time Some College/Vocational/ Homemaker Veteran of US Military Grade 9 or less Comments Medical Insurance Yes No Home Address Same as Primary Caregiver's (Active) Member of Employer / School Name US Military

Agency

• Mid. Init.

Gender B-Day US Citizen Yes No Foster Parent Group Home Eligibility Information Non-English Speaking

(Within the previous 12 months)

Desired Program Option

Part Day, 4 days per week Full Day, 4 days per week Full Day, 5 days per week

Child Information

Current Year Next Year Applicant For

Relation to Secondary Caregiver

Spanish English Special Need Disability Status Teen Parent Child Protective Services Student Parent No Suspected Certified IEP Certified IFSP Death of Immediate Family Member Homeless Disabled Parent Other __________________

Relation to Primary Caregiver

Middle-Eastern Languages Middle-Eastern Languages Language Race Pacific Island Languages Other __________________ English First Name Other____________ Pacific Island Languages

• App. Date

Other Language Spanish White Bi/Multi-racial Unspecified Demographic Information Male Female Ethnicity Native American Last Name Desired Center Center 1 Center 2 Center 3 Guardian (Check all that apply) Grandparent Dual Custody Hispanic Asian Black Pacific Islander Parental Status

Name Male Female D.O.B. Name Male Female D.O.B. Name Male Female D.O.B. Name Male Female D.O.B. Name Male Female D.O.B. Please give directions to your home (be very specific) Name Phone # Name Phone # Name Phone # Name Phone # Emergency Contact: Yes No

I authorize the above designated persons to be contacted in case of emergencies and/or for release of my child. I certify that all information that I have provided in this application is complete and correct. I understand that if I knowingly provided false information, participation in this agency's program may be terminated and my family may not be eligible for further services. I also understand that the information provided will be kept confidential.

Yes No

Additional Information

Release to: Emergency Contact: Yes No Relation to Child Release to: Relation to Child Yes No Yes No Release to: Emergency Contact: Yes No Emergency Information Relation to Child Family Size

In order to help establish program eligibility, we must determine the size of your family using the definition of "family" found in 45 CFR Part 1305.2(e) of the Head Start Program Performance Standards. This definition states that family means "all persons living in the same household who are: (1) Supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program, AND (2) related to the parent(s) or guardian(s) by blood, marriage, or adoption OR (3) the child’s authorized caregiver or legally responsible party.

Staff Signature Parent / Guardian Signature Date Title / Position Total # of family members

(including child & caregivers)

Will you need Head Start to transport your child to and from school each day? Relation to Child Relation to Child Transportation Release to: Yes No Emergency Contact: Yes No Yes No

Notes for Completing the Enrollment Application



There must be a selection made for “Race”. Even if ethnicity is marked as “Hispanic”, there still must be a race selected.



For “education level”, you will select the highest one that has been COMPLETED by the parent. The completion date will be for that particular level of education, not a future date.



Under “employment status”, if you mark that the parent is employed full-time, part-time, or job training/school, then something should be listed in the section of “Employer/School Name.”



Be sure to ask for an email address. We need that to contact parents with information and surveys.



Home Address: This section is the physical, 9-11 address for the family, not the mailing address.



Other Address: This section would normally be used if the parent has a mailing address that is different from their home

• address. You do not need to use this section as a “previous

address” for the parent.



Family Structure: Either “Single” or “Two Parent” must be selected.



Parent/Guardian Best Descriptor: You will only select one

• ption. Example – If the foster parent is also the grandparent,

you would only select “foster parent”.



Current Housing Start Date: If the parent can’t give you specific day/month/year, ask them for their best guess for the year and then just use January 1 as the month and day.



Recruitment Activities: You must select 1 and only 1.

Notes for Completing the Enrollment Application



On the Secondary Caregiver page, their address should be the same as the Primary Caregiver’s otherwise, they shouldn’t be listed as the Secondary Caregiver. The only exception to that rule would be if there was a true “Dual Custody” case and the caregivers live apart. Dual custody means that parents have a 50/50 time split with the child instead of the traditional custody arrangement. Note: If you do have a case of Dual Custody, contact your

• ffice for instructions because family members are not

counted the same way and neither is income so you will need their guidance.



Parental Status: If the parent is a teenager ON THE DAY OF THE APPLICATION, then you would mark “teen parent”.



Parental Status: Several items may be marked. Note: Guardian and Foster Parent cannot both be marked.



Family Size: If a person counts in the child’s family, then they must be listed in this section with all the requested information.



Family Size: If a person is living in the child’s home but do not qualify to be listed in the child’s “Family”, then don’t list them in this section or count them in the family number.



Emergency Information: You will not list the PC or SC in this

• section. You must list 2 people with 2 different phone

numbers in this section. Note: If you list 2 different phone numbers for the same person, that is only 1 emergency contact (2 are required). If you list 2 different people with the same phone number, that is still just one emergency contact.

Legal Name Change For: Child (Check One) Change From: Parent Change To: Change of Address / Phone: Type Transportation: Child Primary Caregiver Secondary Caregiver

Release To Contact

Name: Phone: Yes No Yes No Name: Phone: Yes No Yes No List information for the new caregivers:

PC Name SC Name

D.O.B. D.O.B. Gender Gender Education Level Education Level Employment Status Employment Status Employer Name Employer Name If you have any additional comments concerning a change in this child's information, please list them on the lines below:

Change of Status

Please use this form to record necessary changes made during the year to the original child and family information listed

• n the application. This sheet should then be attached to the application. The parent is only required to sign this form if

he/she is making a change in the Emergency Contact Information section.

Child Name Classroom Teacher Center

This section should only be used if the child has been placed with a new family

Directions to Home: Change of Insurance:

Parental Status Comments

Staff Signature Date

Parental Status has now changed to the following: Biological Parents Foster Care Other

General Information

New Address: New Phone #(s):

Identify if phone # is home, work, or cell in "type" space

Pick up location: Parent/Guardian Signature: Drop off location: New Insurance

Emergency Contact Information

Previous Insurance

Please use the sections below and the corresponding boxes to add or delete individuals (from the orginal list given by the parent) that a child may be released to or may be contacted in case of an emergency. You will also use this section to change phone numbers for emergency contacts. If the person will not be an emergency contact, the phone # is not required.