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Head Start
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Early Head Start Application
HEAD START/EARLY HEAD START APPLICATION
Child's Name
*
(As name appears on birth certificate)
First
Middle
Last
My Child is
*
Under 3 years
3 or 4 years
DOB
*
MM slash DD slash YYYY
Gender
*
Female
Male
CHILD’S RACIAL/ETHNIC BACKGROUND (Check all that apply):
*
White
Black/African American
Asian
American Indian / Alaska Native
Native Hawaiian/Other Pacific Islander
Other
If other by specify
*
Hispanic/Latino
*
Yes
No
Primary Language:
*
English
Spanish
American Sign Language
Child's Secondary Language:
*
English
Spanish
American Sign Language
Primary Language At Home:
*
English
Spanish
American Sign Language
Child's English speaking ability?
*
Very Well
Well
Not Well
Not at all
HOME ADDRESS:
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Do you have a different MAILING ADDRESS?
Yes
No
MAILING ADDRESS:
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
CHILD LIVES PRIMARILY WITH: (Check all that apply)
*
Both parents/Same house
Mother
Father
Legal Step-Parent
Girlfriend
Boyfriend
Grandparent(s)
Foster Parent
Other
If other by specify
*
Is one parent away on military duty?
*
Yes
No
Is mom pregnant?
*
No
Yes
Unsure
When is the due date:
WHAT IS THE CURRENT LIVING ARRANGEMENT (Check one)
*
Rent
Own
Relative/Friend provides a stable home
Staying with family/friends short term
Transitional housing
Motel
Shelter
Mission/Church
Living in car, park, campgrounds, public spaces, abandoned buildings, or poor quality housing
PRIMARY PARENT / LEGAL GUARDIAN #1
Name
*
(As name appears on birth certificate)
First
Middle
Last
DOB
*
MM slash DD slash YYYY
Status
Single
Married
Divorved
Separated
Widowed
Race/Ethnicity
*
White
Black/African American
Asian
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Hispanic?
*
Yes
No
Primary Language:
*
English
Spanish
American Sign Language
Relationship to child
Birth Mom
Birth Dad
Legal Step-Parent
Adoptive
Foster
Guardian
Is different than the child's family
*
Yes
No
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
EMAIL
*
PRIMARY PHONE:
*
Is this number
*
Home Number
Cell Number
Work Number
Opt in for text messages
*
Yes
No
SECONDARY PHONE:
*
Is this number
*
Home Number
Cell Number
Work Number
Highest grade completed:
*
English speaking ability?
*
None
Little
Moderate
Proficient
Did you receive?
*
High School Diploma
HSED/GED
None
PRIMARY PARENT / LEGAL GUARDIAN #2
Name
(As name appears on birth certificate)
First
Middle
Last
DOB
MM slash DD slash YYYY
Status
Single
Married
Divorved
Separated
Widowed
Race/Ethnicity
White
Black/African American
Asian
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
Hispanic?
Yes
No
Primary Language:
English
Spanish
American Sign Language
Custody
Yes
No
Shared
Relationship to child
Birth Mom
Birth Dad
Legal Step-Parent
Adoptive
Foster
Guardian
Is address different than the child's family?
*
Yes
No
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
EMAIL
PRIMARY PHONE:
Is this number
Home Number
Cell Number
Work Number
Opt in for text messages
Yes
No
SECONDARY PHONE:
Is this number
Home Number
Cell Number
Work Number
English speaking ability?
None
Little
Moderate
Proficient
Highest grade completed:
Did you receive?
High School Diploma
HSED/GED
None
IS YOUR CHILD CURRENTLY IN?
*
Birth-3
Early Childhood/Special Education
WEAP
None
Other Home Visitation Program
if Other Home Visitation Program, specity
*
Was your child on a waitlist last year?
*
Yes
No
If YES, what State/County
*
DOES YOUR CHILD CURRENTLY HAVE?
*
IFSP
IEP
NO
What IFSP services are they receiving? (Check all that apply)
Speech / Language
Early Intervention
Physical Therapy
Occupational Therapy
Other
If Other, please specity
*
What IEP services are they receiving? (Circle all that apply)
Speech / Language
Early Childhood
Physical Therapy
Occupational Therapy
Other
If Other, please specity
*
ARE YOU CONCERNED ABOUT ANY OF THE FOLLOWING FOR YOUR CHILD?
*
Physical
Health
Learning
Speech / Language
Vision
Hearing
Interacting in a group setting
Emotional
Behavioral
Other
None
If Other, please specity
*
DO YOU HAVE ANY FAMILY CONCERNS?
*
Reading Difficulties
Writing Difficulties
Parent has/had an IEP
Continuing Education
Transportation
Parent has a chronic illness
Mental Health
Not enough food in the home
Shelter / Homelessness
Unemployed / Not enough hours
Alcohol / Drug use
Legal Concerns
One parent is incarcerated
Both parents are incarcerated
One or both parents are deceased
Other
None
If Other:
*
HOW DID YOU FIND OUT ABOUT US?
*
Job Center
Birth-3
Social media / Internet
Community Health Program/WIC
Public School Staff
Friend/Family
Health & Human Services
WEAP
Famliy Resource Center
Early Head Start/Head Start Staff
Other
If other, specify
*
DOES ANY MEMBER OF THE HOUSEHOLD RECEIVE ANY OF THE FOLLOWING?
*
Check all that apply.
Food Stamps
Health Insurance (State or private)
Caretaker Supplement
W2 / Cash Assistance
Survivor’s Benefits
Child Support for
ANY
child in the home
Public Housing / Section 8
Energy Assistance
Child Care Assistance
WIC / Healthy Start
Other
None
If other, specify
*
LIST CHILD’S SIBLINGS CURRENTLY LIVING IN THE HOME:
Please use the + sign to add additional siblings.
Name (First and Last)
Relationship to child
Male/Female
DOB
ADDITIONAL CONTACT PERSON(S) IF WE ARE UNABLE TO REACH YOU:
Name
First
Last
Relationship
Phone
Name
First
Last
Relationship
Phone
PLEASE READ STATEMENTS BELOW CAREFULLY BEFORE SIGNING
Application will not be complete until we have proof of income. For enrollment purposes, I understand that RWCFS Head Start/Early Head Start may need to coordinate programming with my local school district, WI Shot Registry, other home visitation programs, and/or daycare providers for transportation, placement, 4K registration, and scheduling.
By signing, I verify that I am the parent/legal guardian of this child and that the information provided is correct and complete to the best of my knowledge.
I further understand that if I knowingly provide false information, that my family may no longer be eligible for further services.
Sign and Date
(When both parents live in the home, then both should sign whenever possible)
Parent/Guardian Signature
*
Enter today's date
*
MM slash DD slash YYYY
Parent/Guardian Signature
Enter today's date
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.
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