SOUTHWESTERN COMMUNITY ACTION COUNCIL, INC
Lincoln County Schools Collaborative Pre-K Program
2019-2020 School Year Eligibility Registration
Southwestern Community
Action Council Inc. Head Start
Site Location 1st Choice: _______________ Site Location 2nd Choice: _______________
Home School: ____________________ Date of Application: _________________
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A. Enrollee Data: Child Resides with Whom?: __________________ Language Spoken in Home: ________________________
|Last Name |First Name |M.I. |
|1. | | |
|2. | | |
|3. | | |
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K. Income Data: Please complete the requested information below.
* The income information will be evaluated according to the “Income Guidelines” established by the United States Department of Health and Human Services to determine Head Start eligibility. All information will be strictly confidential. When submitting application attach the most current check stubs (for 12 months), W-2 Form, TANF verification, SSI verification, 1040 form, Child support, Foster Care, Unemployment Compensation, and/or affidavit of no income signed.
Do you currently receive TANF funds (Temporary Aid for Needy Families) or have Please circle: YES or NO
you received these funds in the past twelve months?
Do You or any family member receive SSI payments (Supplemental Security Income)? Please circle: YES or NO
Do You or any family members receive WIC vouchers (Women, Infants and Children)? Please circle: YES or NO
Do you or your family members receive any other type of assistance (e.g. SNAP)? Please circle: YES or NO
If so, please list:______________________________________________________________________________________________
___________________________________________________________________________________________________________
Concerns about child’s overall health and development? Please circle: YES or NO
If YES describe concerns: ______________________________________________________________________________________
Is Your Child Potty Trained? Please circle: YES or NO
If no, does your child wear diapers or pull-ups?________________________________
Survey: For Pre-K in the future would you as a parent a prefer 4 day or 5 day a week program:____________________________
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