SOUTHWESTERN COMMUNITY ACTION COUNCIL, INC



Mason County Schools Collaborative Pre-K Program

2019-2020 School Year Eligibility Registration

Mason County Site Location 1st Choice: _________________ Site Location 2nd Choice: _________________

Board of Education

Home School for Kindergarten: ____________________ Date of Application: _______________

A. Child Data: With whom does child reside: _______________ Language Spoken in Home: _____________

|Last Name |First Name |Middle Name |

|1. | | |

|2. | | |

|3. | | |

L. Financial Information: Please complete the requested information below. The income information below 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. If you meet eligibility guidelines and are interested in receiving additional support services, you will be asked to provide documentation that verifies the information provided by you.

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 month?

Do you or any family members 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 any 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: ______________________________________________________________________________________

Please place an (X) beside the annual income range of your household?

______ $0.00 - $12,140 ______ $32,630.00 - $38,246.00

______ $12,140.00 - $15,782.00 ______ $38,246.00 - $43,862.00

______ $15,782.00 - $21,398.00 ______ $43,862.00 - $49,478.00

______ $21,398.00 - $27,014.00 ______ $49,478.00 - $55,094.00

______ $27,014.00 - $32,630.00 ______ Over $55,094.00

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