Capc Head Start/early Head Start Program Application Page 3
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3HS/EHS Application, Page 2 of 2
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
Legal Guardian
Yes
No
C. Other members in household you support (Do not include anyone listed above)
First Name
Last Name
Date of Birth
Relationship to child
First Name
Last Name
Date of Birth
Relationship to child
First Name
Last Name
Date of Birth
Relationship to child
First Name
Last Name
Date of Birth
Relationship to child
First Name
Last Name
Date of Birth
Relationship to child
Referred by
D. Other ways we can reach you (people we can call and your e-mail address)
First Name
Last Name
Phone Number
First Name
Last Name
Phone Number
E-mail 1
E-mail 2
I certify that the information given in this application is correct and true. I understand that should the program determine that the information
given is false or incorrect; my child could be dropped from the program.
Parent Signature:
Date
Items below are For Office Use Only
The following documents are attached:
Yes
No
N/A
1) Child's Birth Certificate
2) Proof of family income with signed eligibilty verification
3) Proof of Residency
4) Guardianship Papers (If Applicable)
5) IEP/IFSP (If Applicable)
Intake Staff Signature
Date
Application is Complete and ready to submit to Admissions
Intake Staff Signature
Date
Application has been verified by Admissions
Admissions Staff Signature
Date
Family Size
100% Poverty
130% Poverty
Family Size
100% Poverty
130% Poverty
1
$11,770
$15,301
5
$28,410
$36,933
2
$15,930
$20,709
6
$32,570
$42,341
3
$20,090
$26,117
7
$36,730
$47,749
4
$24,250
$31,525
8
$40,890
$53,157
For families with more than 8 persons, add $4,160 for each additional person
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