PRE-NATAL APPLICATION - Rock County, Walworth County Head Start / Early Head Start

Our prenatal program helps pregnant women receive education and a further understanding of the medical care they and their growing babies need. A home visitor will work with you to provide information support as you prepare for the birth of your baby.

Specialized services are provided by certified Doulas for pregnant and postpartum moms.

This service is currently only available in Rock County and space is limited.

Prior year’s proof of income and an interview are required to determine your eligibility in the program. Completing the application does not mean you are accepted.

Pregnant mothers with the greatest need for services will be placed first.

Please complete the application thoroughly so we know how to best serve you.

All information is kept confidential

What DOULAS do.

WE ARE AN INCOME BASED PROGRAM AND WILL NEED YOUR PRIOR YEAR’S INCOME:

If you currently receive one of the following we will need verification.
Example: award letter or current statement

SSI
W2 Cash Assistance
Food Share (SNAP)
Foster Care Supplement
Kinship Care

If the incomes above do not apply to you, please send copies of all incomes below that apply to your family:

Tax Return
SSDI
W2 Employer Statement
Caretaker’s Supplement
Unemployment Compensation
Written statement from the employer
Written statement for cash received for work
Child Support received for all children in the home

If none of these apply to you, please contact the enrollment office.

Please allow up to 30 days for processing the application. Incomplete applications will not be considered for placement.

Please contact us with new address/phone number changes.

If you have any questions or need help with anything please call/email us:

Janice Kuchelmeister
[email protected]

Danielle Daringer
[email protected]

Nancy Marx
[email protected]

PRE-NATAL APPLICATION FOR ENROLLMENT

"*" indicates required fields

MOTHER’S INFORMATION

Name*

(As name appears on birth certificate)

First Middle Last

DOB*

EMAIL*

PRIMARY PHONE:*

Is this number*

Home Number

Cell Number

Work Number

Opt in for text messages*

Yes

HOME ADDRESS:*

Street Address City State ZIP Code

Do you have a different MAILING ADDRESS?

Yes

MAILING ADDRESS:*

Street Address City State ZIP Code

ADDITIONAL CONTACT PERSON(S) IF WE ARE UNABLE TO REACH YOU:

Name

First Last

Relationship

Phone

Name

First Last

Relationship

Phone

LIST SIBLINGS TO THE UNBORN CHILD IN THE HOUSEHOLD

Please use the + sign to add additional siblings.

Name (First and Last)

Relationship to child

Male/Female

DOB

Primary Language:*

English

Spanish

American Sign Language

Other

English speaking ability?*

Did you complete Elementary School?*

Yes

Did you receive?*

High School Diploma

HSED/GED

None

Race/Ethnicity*

White

Black/African American

Asian

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Other

Hispanic?*

Yes

FATHER’S INFORMATION

Name

(As name appears on birth certificate)

First Middle Last

DOB

PRIMARY PHONE:

Is this number

Home Number

Cell Number

Work Number

Opt in for text messages

Yes

Is Address different than the mother's?*

Yes

ADDRESS IF DIFFERENT THAN THE MOTHER'S*

Street Address City State ZIP Code

Primary Language:*

English

Spanish

American Sign Language

Other

English speaking ability?*

Very Well

Well

Not Well

Not at all

Did he complete Elementary School?*

Yes

Did he receive?*

High School Diploma

HSED/GED

None

Race/Ethnicity*

White

Black/African American

Asian

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Other

Hispanic?*

Yes

MARITAL STATUS OF BIRTH PARENTS*

Married/Living Together

Never Married/Living Together

Legally Married/Not Living Together

Never Married/Not Living Together

Divorced

Widowed

PREGNANCY INFORMATION

What trimester of pregnancy are you in*

First

Second

Third

Due Date*

Number of past pregnancies*

(Do not count your current pregnancy)

Number of live births*

Have you ever been pregnant with multiples?*

Yes

Are you receiving prenatal care:*

Yes

Do you or your doctor have any concerns with your pregnancy?*

Yes

Comment briefly:

CURRENT LIVING ARRANGEMENT*

Rent

Own

Staying with family/friends long term

Foster Home

I am homeless

Other

Homeless - This means that you are staying in a car, park, campgrounds, hotel, emergency shelter, transitional housing, on the street, or are living with family/friends short term.

If homeless, please check which applies to you:

Motel/Hotel

Shelter

Mission/Church

Transitional Housing

Staying on the street

Family/Friends short term

DO YOU HAVE ANY FAMILY CONCERNS?*

If Other:*

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

If other, specify*

HOW DID YOU FIND OUT ABOUT US?*

If other, specify*

PLEASE READ STATEMENTS BELOW CAREFULLY BEFORE SIGNING

Family income is the income of the biological parent(s) / adoptive parent(s) or guardian(s) living in the household. For enrollment purposes, I understand that RWCFS Head Start-Early Head Start may need to coordinate programming with my local school district, and other home visitation programs for placement.
By signing, I verify 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.