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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