Commission on Economic
HEAD START / EARLY HEAD START ENROLLMENT APPLICATION
Child’s
Name_____________________________________________________________________________
Application
Date: ___________________ Birth Date_________________
Gender: _____M ______F
Special
Needs_____________________________________________________________________________
Comments:
______________________________________________________________________________
_________________________________________________________________________________________
Program
Model: _____ EHS / ______HS / _______Extended
Day
Center
Preferred_______________________________________ Hours per Day:
_____________________
Transportation
needed: Yes / No
Primary Parent / Guardian
Information
Name:
_________________________________________________________________________________________
Address:
____________________________________________Phone:_____________________________________
City
/Town:
Gender:
_________M ________F Birth
Date: _________________________
Age: _____________
Ethnic
Background: _____White _______ Black _______
Bi-Racial _______Hispanic ________ Asian or Pacific Islander ________
Native
American _________ Other_______________________________________
Language:
____________________________________Second
Language: __________________________________
Social
Security Number:
__________________________________________________________________________
Education
Level: __________________________ Employment
Status:
___________________________________
Secondary
Parent / Guardian Information
Name:
___________________________________________________________________________________________
Address:
____________________________________________Phone:_______________________________________
City
/Town:
Gender:
_________M ________F
Birth Date: _________________________
Age: _____________
Ethnic
Background: _____White _______ Black _______
Bi-Racial _______Hispanic ________ Asian or Pacific Islander ________
Native
American _________
Other____________________________________________________________
Language:
____________________________________Second
Language: ____________________________________
Social
Security Number:
_____________________________________________________________________________
Education
Level: __________________________ Employment
Status:
______________________________________
Have
you and your family been homeless in the past
year? _______ yes _______ no
Number
of People in family: __________ Number
of people living in household:
_________
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First
and last Name |
Sex |
Date
of Birth |
Relationship |
Any
Special Needs |
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Do you
feel your child has any Special and or Medical
Needs such as?
Speech
__________ Hearing __________ Behavior
____________ Emotional ___________ Other__________
Do you
and your family have health Insurance? _____
yes _____ no Health Ins. Provider ________________________
Has a
doctor diagnosed your child with any special /medical
needs? ________yes _______ no
Is your
child receiving services for special education
/ medical needs? ___________yes
_________no
If yes
what type of services?
__________________________________________________________________
__________________________________________________________________________________________
Please
feel free to talk to the Center Manager about
your concerns, and they will attempt to answer all your questions or
find out
the answers to your questions.
Has
your child ever attended a Preschool program
before? __________________________________
Are you
currently receiving WIC or any other CEO
services? ___yes ___no
If yes
which programs?
______________________________________________________________________
Do you
have an open case with Child Protective
Services? _____yes ____ no
Are you
receiving treatment for drug or alcohol
abuse? ______ yes ____
no
Is
anyone in your family incarcerated? _____
yes _____ no
All
children enrolled in Early Head Start/ Head Start
full day will receive breakfast, lunch and a mid-day snack.
My
child will attend ________ MON_______ TUES_______ WED_______
THURS_______ FRIDAY.
Hours
of attendance: ________________________
HEAD
START AND EARLY HEAD START ARE FEDERALLY FUNDED
PROGRAMS. ACCEPTANCE IS BASED ON INCOME ELIGIBILITY. IN ORDER FOR US TO
CONSIDER YOUR CHILD’S APPLICATION WE MUST HAVE PROOF OF INCOME.
(PLEASE SUBMIT WITH
APPLICATION)
_____
SSI ______UNEMPLOYMENT ______DISABILITY/
COMPENSATION______ CHILD SUPPORT
________US
INDIVIDUAL TAX RETURNS (PREVIOUS YEAR) ______
PAY STUBS _____ LETTER FROM EMPLOYER _______BIRTH CERTIFICATE______
BAPTISMAL
RECORD _______ IMMUNIZATION RECORD _______BENEFIT CARD ______ HEALTH
INSURANCE
CARD
Longer Day Programming requires one
or both parents to be working or attending an educational program.
There may be
a weekly fee involved for the additional hours of child care in the
extended
day classrooms.
Please
provide following information to be considered for the extended day
rooms:
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Relationship |
Employment
or School |
Phone
Number |
Hours Work/School |
Alternate
Number |
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I
understand that Head Start/ Early Head Start staff
members will make periodic home visits, and that my child will
participate in
all aspects of the Head Start program, unless restricted by religious
or
medical reasons.
Parent/
Guardian
Signature_________________________________________ Date:
______________________
Please
Print Full Name:
________________________________________________________________________
For
office use only: TYPE OF INCOME: __________________Total
Yearly Gross Income _______________________
_________
100% Income Eligible ________ 130%
Poverty Guideline _________
Over Income (Refer to Daycare)
Staff
Signature ______________________________________________
Date: ________________________
_______BIRTH
CERTIFICATE______ BAPTISMAL RECORD
_______ IMMUNIZATION RECORD _______BENEFIT CARD ______ HEALTH INSURANCE
CARD
Staff
Signature: ____________________________________________________________
Date: ____________
Center
Manager/ Assistant CM: _______________________
Date: _________ ERSEA Manager: _____________
CEO Head Start Centers
Stepping Stones I
518-235-9061
518-694-9915
518-686-5045
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