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*

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

HOME ADDRESS:*

Street Address City State ZIP Code

Do you have a different MAILING ADDRESS?

Yes
No

MAILING ADDRESS:*

Street Address City State ZIP Code

CHILD LIVES PRIMARILY WITH: (Check all that apply)*

Both parents/Same house
Mother
Father
Legal Step-Parent
Parent's Significant Other
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:

DO YOU HAVE ANY OF THE FOLLOWING FAMILY CONCERNS*

House Fire
Frequent Moves (2+ a year)
Chronic illness/ terminal illness
Immigration Concerns

WHAT IS THE CURRENT LIVING ARRANGEMENT (Check one)*

PRIMARY PARENT / LEGAL GUARDIAN #1

Name*

(As name appears on birth certificate)

First Middle Last

DOB*

Status

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

Is different than the child's family*

Yes
No

Address*

Street Address City 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

Status

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

Is address different than the child's family?*

Yes
No

Address

Street Address City 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?*

If Other, please specity*

DO YOU HAVE ANY FAMILY CONCERNS?*

If Other:*

HOW DID YOU FIND OUT ABOUT US?*

If other, specify*

DOES ANY MEMBER OF THE HOUSEHOLD RECEIVE ANY OF THE FOLLOWING?*

Check all that apply.

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*

Parent/Guardian Signature

Enter today's date

Name

This field is for validation purposes and should be left unchanged.