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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