Family And Early Childhood Education Program/head Start/early Head Start Application Page 3
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Section 4: Family Resources and Situations
Resources your family receives (check all that apply):
SNAP
SSI
TANF/View
Wic
Is your family currently homeless? Yes
No
Has your child ever received a service from FCPS before? Yes
No
If yes, specify:
Are you able to provide transportation (this does not affect eligibility?) Yes
No
Section 5: Parent or Legal Guardian Child Dependents.
List all child dependents living in the home, such as brothers and/or sisters.
If additional space is needed you may attach another sheet.
Does this child
Date of
Gender:
currently live w ith
Last Name
First Name
Age
Birth
Male or Female
you?
M
F
Yes
No
M
F
Yes
No
M
F
Yes
No
M
F
Yes
No
M
F
Yes
No
Section 6: Emergency Contacts
List contacts who can reach you if we are not able contact you at the phone numbers
Relationship to
First Name
Home Phone
Cell Phone
Last Name
child applicant
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