Capc Head Start/early Head Start Program Application Page 2
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CAPC Head Start/Early Head Start Program Application
Head Start (Center based)
Early Head Start
Head Start (Childcare partner)
Head Start (Title 1 site)
Current year
Next year
A. APPLICANT (CHILD APPLYING FOR SERVICES)
First Name
Middle Name
Last Name and Suffix
Date of Birth
Gender
Male
Female
Race
Primary Language
Ethnicity
Asian
American Indian or Alaskan native
English
Korean
Hispanic or Latino Origin
Black or African American
Native Hawaiian/Pacific Islander
Spanish
Vietnamese
White
Bi-Racial/Multi Racial
Arabic
Other
Non-Hispanic or
Other:
Vietnamese
Chinese
___________
Non-Latino Origin
Living Address
Address Line 2
Zip Code
City
State
Mailing Address (if Different)
Address Line 2
Zip Code
City
State
Contact Number
Type
Alternate Number
Type
B. Primary Parent or Guardian
First Name
Middle Name
Last Name
Date of Birth
Gender
Male
Female
Race
Primary Language
Ethnicity
Asian
American Indian or Alaskan native
English
Korean
Hispanic or Latino Origin
Black or African American
Native Hawaiian/Pacific Islander
Spanish
Vietnamese
Arabic
White
Bi-Racial/Multi Racial
Other
Non-Hispanic or
Other:
Vietnamese
Chinese
___________
Non-Latino Origin
Employment Status
Student Status
Custody Arrangement if applicable
Paternal rights estabilshed?
Full-time (35 or more hrs a week)
Full-time
Permanent
Temporary
Yes
No
Income Received (documentation required for past 12 months)
Part-time (less than 35 hrs a week)
Part-time
Self employed
Not a student
Wages
Alimony
Unemployment
Unemployed
School Name
SSI/SSDI
Scholarships
Grants
TANF
Retired or Disabled
Child Support
Veteran's
Pension
Other
Highest Grade completed
Parent's relationship to child
Lives in house with child
Grade 10 or less
College degree/training cert
Natural/adopted/step child
Yes
No
Grade 11
College or advance training
Foster child
Did parent go to Head Start
GED
Associate Degree
Grand child
Yes
No
Certificate of completion
Bachelor's Degree
Niece or Nephew
Other kids in Head Start
High School Graduate
Master's Degree
Legal Guardian
Yes
No
Please select all the below items that are TRUE about your household
Child abuse or neglect
Homeless
Active duty military
Receive SNAP (food stamps)
Receive WIC
Applying child has an IEP/IFSP
Applying child has a suspected disability
At Risk
In Crisis
C. Secondary Parent or Guardian
First Name
Middle Name
Last Name
Date of Birth
Gender
Male
Female
Race
Primary Language
Ethnicity
Asian
American Indian or Alaskan native
English
Korean
Hispanic or Latino Origin
Black or African American
Native Hawaiian/Pacific Islander
Spanish
Vietnamese
White
Bi-Racial/Multi Racial
Arabic
Other
Non-Hispanic or
Other:
Vietnamese
Chinese
___________
Non-Latino Origin
Employment Status
Student Status
Income Received (documentation required for past 12 months)
Full-time (35 or more hrs a week)
Full-time
Wages
Alimony
Unemployment
SSI/SSDI
Grants
TANF
Part-time (less than 35 hrs a week)
Part-time
Scholarships
Self employed
Unemployed
Not a student
Child Support
Veteran's
Pension
Other
Retired or Disabled
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