HEAD START/EARLY HEADSTART ENROLLMENT APPLICATION

HEAD START & EARLY HEAD START ENROLLMENT APPLICATION

Child¡¯s Legal Name

First

THE CHILD¡¯S INFORMATION

Middle Initial

Child¡¯s Place of Birth (City, State)

Child¡¯s Ethnicity

Latino

Yes

No

Child¡¯s Primary Language

English

Spanish

Vietnamese

Other _________

Race

2 Secondary adult (if any)

Latino?

Race

Yes

No

Primary Language if different

from child

Yes

No

Marital Status:

Single

Married

Divorced Separated

Residential Address

HS

LIFT

Sex

Child¡¯s Secondary Language

English

Spanish

Vietnamese

Other _________

THE CHILD¡¯S HOUSEHOLD FAMILY INFORMATION

Latino?

EHS

Child¡¯s DOB (mm/dd/yyyy)

Child¡¯s Race

Pacific Islander

Black

White

Biracial/ Multi

Nat. Amer.

Asian

Other_____________

1 Primary adult name

City

EHS-CCP

Last

Secondary Language if

Different from child

Parental Status:

One parent

Two parents

Foster parent

Mailing Address (if different from Residential Address)

State

CA

Zip Code

City

State

Zip Code

Primary Phone Number (including area code)

Home

Other Phone (including area code)

Home

Work

Cell

Cell

Message

Current Housing:

Rent Own

Homeless

Total in

Ok to text?

Ok to email?

YES

NO

YES

NO

Other______________

Family ______

If not homeless, date you moved in_______________

Is your child related to a Preschool Services Department Employee?

Yes

No

Previous Housing: Rent Own Homeless

Employee Name & Relationship to child: _______________

Site: ___________

Other_______________

Email Address:

Family Receives:

SSI

YES

NO

TANF/CalWORKS YES

NO

Does family receive WIC?

Yes

No

How did you hear about us?

Former Parent

Family Friend

1

ELIGIBILITY INFORMATION

Does Child Have Insurance? Check if applicable:

Medi-Cal

IEHP

Healthy Families

Other_________

Emergency

None

Does Family Receive

CalFRESH (EBT)?

Yes

No

Does Family Have Medical Insurance?

Yes

No

Does Child Have Dental Insurance?

Yes

No

Community Event

Flyer/Poster

School District Community Partner Referral

Other Head Start

State Preschool Facebook Local Community Agency Referral

Public Advertisement

Online

Other ___________________________________

Mailings

Public Service Announcements (TV/Radio)

PARENT AND/OR GUARDIAN

INCOME SOURCE

Employment

Disability

Unemployment Benefits

Other_________

2

Employment

Disability

Unemployment Benefits

Other_________

PRENATAL INFORMATION

N/A

Pregnant before Enrollment

First Pregnancy

Expected delivery date: _______________

School/Training

1

ADULT HOUSEHOLD FAMILY MEMBER INFORMATION (18 and older only)

(Please only include adults in the household supported by the income of the parent.)

(Enter Primary Adult First)

Education

Date of

How Related to

Sex

Employment

First & Last Name

Level

Birth

Applicant

circle one:

FT PT N/A

2

FT PT N/A

FT PT N/A

3

FT PT N/A

FT PT N/A

4

FT PT N/A

FT PT N/A

circle one:

FT PT N/A

G:\ERSEA\Forms\Head Start\Head Start-Early Head Start Enrollment Application English.doc Revised.12/19/2018

First & Last Name of Children in

Home

How Related to Applicant

1

2

3

Date of Birth

Sex

Notes

Applied Child

4

5

6

INFORMATION

At least one parent/guardian is a member of the United States military on active duty

Yes

At least one parent/guardian is a veteran of the United States military

Yes

No

What type of transportation do you use? Check one.

Car

Bus

Walk

Other

If available, is a Head Start school bus needed?

Yes

No If needed, why?

No

Children with special needs may receive priority for Head Start enrollment. Your disclosure of this information is strictly

voluntary.

1. Does your child have a disability? ________ (If no, please go to question #6)

2. Type of special need or disability _____________________________________

3. Has the disability been professionally diagnosed?

(If yes, at what age ________?

By whom? ____________

4. Does the child have an IFSP/IEP?

________

5. Is the child receiving special services for the disability? ______________________

6. In your opinion, does your child have a special need that has not yet been diagnosed?

If yes, please explain: ______________________________________________________________

Certification: I certify that this information is true. If any part is false, my participation in this agency¡¯s program may be

terminated. I also understand that the information in this application will be held in strict confidence within the agency and is

accessible to me during normal business hours.

Children and pregnant mothers that are determined to be eligible for the Early Head Start program are

eligible until the child turns 3 years old (4 years old if the child is in family child care).

Applicant Signature :

Date:

Initial Enrollment

Program Year: 2019-2020

TO BE COMPLETED BY STAFF

Center Name:

Family ID:

Acceptance Status (circle):

Program Type:

EHS

LIFT

EHS-CCP

Accept

Denied

Income Eligibility (select only one):

Income (below federal poverty guidelines)

Child ID:

HS

Program Option

Home Base

Over-income

Documents Verified (select as many as apply):

Check Stub

W2

Written Statement from

Employer

TANF/CalWORKs

SSI

Unemployment

Document of no income

Total Annual Income:

Birth Verified By

Other _______________________

$______________________

Birth Certificate

Medi-cal Card

Verifying Staff Member

Signature:

Parent Signature (2nd Year)

Travel Passport

Other __________

Full Day

Categorical Eligibility (select one):

Homeless

Foster Care

Documents Verified (select one):

Foster Care Reimbursement

Statement from homeless

services provider

Other _______________

Age by September 1st:

Print Name

Passport

First Day Child

Attended Class (Entry):

Part Day

EHS/CCP ONLY:

CD 9600 date:

________

First date of subsidized

service:______________

Months at time of Enrollment

(EHS & EHS-CCP only):_______

Date:

Date:

Parent confirms eligibility for 2nd year of Head Start based on Head Start Regulations (1302.12(j)(1))

In-person Interview

Phone Interview Note(s): ______________________________________________________________

______________________________________________________________________

Staff signature ________________

______________________________________________________________________

Date: ________

______________________________________________________________________

G:\ERSEA\Forms\Head Start\Head Start-Early Head Start Enrollment Application English.doc Revised. 12/19/2018

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