Head Start Application - Polk County Public Schools

Polk County Schools--Preschool Programs

Woodlake Center 3425 New Jersey Rd., Lakeland, FL 33803 Tel: (863) 648-3051 Fax: (863) 648-3050

Head Start Application

School Year 2019-2020

In order to avoid any delays in processing your application, please answer all questions. Application must be updated annually.

OFFICE USE ONLY

Please submit all documents. Additional documents may be requested.

ChildPlus ID# ____________________________ Application entered by: _______________________________________ Date: ____________________

1. Childs' Birth Certificate 2. Proof of Guardianship 3. Copy of last 2 check stubs 4. Copy of 2018 1040 tax return

5. Any type of income (TANF/SSI, Pell Grant, Unemployment, Scholarships)

6. Proof of Address (2)

School Choice: First Choice:

Applicant (child for services) First Name

Middle Name

Second Choice: Last Name

Date of Birth / /

Gender M F

Hispanic/Latino

Race

Primary Language Spoken

Yes No

Asian White

Indian/Alaska Native

English French Haitian Creole

Black Multi-Racial Other _____________ Spanish Arabic Other ___________

Parent/Guardian 1 (Primary)

E-mail Address:

Foster Child

Yes No

First Name

Last Name

Date of Birth / /

Marital Status

Married Single Partners Divorced Separated

Gender M F

Lives with family?

Yes No

Phone Numbers

Cell (____) _____-__________ Home (____) ____-__________ Work (____) ____-________ Contact via text? Yes No

Hispanic/Latino

Race

Primary Language Spoken

Highest Grade Completed

Yes No

Asian Indian/Alaska Native Black Multi-Racial

White Other ____________

English Spanish Arabic Haitian Creole

French Other ______

Grade 9 or below High School Grad Tech/Trade

Grade 10 or 11 GED

A.A. Degree

Other _______________________________________

Current Employment Status

Full Time Unemployed--How Long? ____________ Part Time Retired or Disabled Seasonal School Board Employee or Relative

Currently Enrolled in School

Yes No

Child's Relationship to Adult

Biological/Adopted/Step Foster Grandchild Other __________________

Custody

Yes No Joint

Provides Financial Support

Yes No

Parent/Guardian 2 (Secondary) First Name

Last Name

Phone Numbers

Cell (____) _____-__________ Contact via text? Yes No

E-mail Address:

Date of Birth / /

Marital Status

Married Single Partners Divorced Separated

Gender M F

Lives with family?

Yes No

Home (____) ____-__________ Work (____) ____-________

Hispanic/Latino

Yes No

Race

Asian Indian/Alaska Native Black Multi-Racial White Other ____________

Primary Language Spoken

English Spanish Arabic Haitian Creole French Other ______

Highest Grade Completed

Grade 9 or below High School Grad Tech/Trade

Grade 10 or 11 GED

A.A. Degree

Other _______________________________________

Current Employment Status

Full Time Unemployed--How Long? ____________ Part Time Retired or Disabled Seasonal School Board Employee or Relative

Currently Enrolled in School

Yes No

Child's Relationship to Adult

Biological/Adopted/Step Foster Grandchild Other __________________

Custody

Yes No Joint

Provides Financial Support

Yes No

Living address: _____________________________________ Mailing address: ____________________________________

(If different from living)

_____________________________________

_____________________________________

_____________________________________

_____________________________________

ADDITIONAL Family and Household Members living with the child (Do not list Applicant, Parent 1 and Parent 2)

First/Last Name

Date of Birth Gender

Race

Hispanic

Language

/

/

M F

Yes No

Relationship to Primary Adult

/

/

M F

Yes No

/

/

M F

Total Number in Family (count yourself and all family members supported by the parent's income) __________________________

Additional Emergency Contact:

Name:

Yes No

Total Number in the Household. ___________

Does your child have transportation to school? (Head Start does not provide transportation) Yes No

Emergency contact number:

Homeless Family

Military Veteran Family

Referred by Child Welfare Agency

Receiving SNAP (Food Stamps)

WIC

Yes, If yes answer Residency Status No

Yes No

Yes No

Yes No

Yes No

Residency Status (choose all that apply) Yes No Does the child's family share housing due to economic struggles? (living with other adults, including relatives)

If Yes, please explain _____________________________________________________________________________________________________________

Yes No Is the child living in a shelter, hotel, motel, or lack regular, fixed residence? (domestic violence shelter, transitional housing, etc.) If Yes, please explain _____________________________________________________________________________________________________________

Yes No Is the child living in a car, park, campground, or public place? If Yes, please explain ______________________________________________________________________________________________________________

ALL Family Income MUST be REPORTED (mark each box)

TANF

Supplemental Security Income (SSI)

(Retirement, Disability, Survivors, Dependent)

Yes No

Yes No

Child's Health Information and Developmental Concerns

Foster Care

Yes No

Child Support Date Began __________

Yes No

Unemployment Date Began _____

Yes No

DCF Payment

Yes No

Pell Grant Scholarship

Yes No

Head Start Performance Standards require all children to have current immunizations and well child health and dental exams.

Primary Health Insurance

Medicaid Florida Kidcare (CHIP)

Private None

Doctor Name

Dental Coverage

Yes No

Does your child have any current or on-going medical condition? (Ex: Yes

asthma, heart problems, diabetes, bronchitis, seizures, etc.)

No

If Yes, List and Explain:

Does your child have any health and developmental issues? (Ex: food Yes

allergies, speech, hearing, vision, autism, etc.)

No

If Yes, List and Explain:

Does your child have an active Individual Education Plan (IEP)? No Yes, please attach documentation

Dentist Name

CERTIFICATION (I CERTIFY AND UNDERSTAND THE FOLLOWING)

I certify that all income is reported and the information provided on this application is accurate and truthful to the best of my knowledge. Falsifying information may result in termination from the Head Start Program.

I understand that all required documents must be attached to the application to be processed and that my child/children cannot be considered for Head Start services without documents and verification.

I understand that this information will be reviewed by the Polk County School District Head Start Program to determine eligibility for other Preschool Programs.

I understand I will be responsible for my child's transportation and maintain regular attendance.

Signature of Parent/Guardian: _______________________________________________________

Date: ______________

Printed Name of Parent/Guardian ____________________________________________________ OFFICE USE ONLY

If this applicant is a relative of an employee, application must be reviewed by management.

________________________________

Signature of Management

_________________

Date

Revised 1/30/18

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download