Head Start / Early Head Start Only - Child'S Or Pregnant Mother'S Information Only Form
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1HEAD START / EARLY HEAD START ONLY – CHILD’S OR PREGNANT MOTHER’S INFORMATION ONLY. INCLUDE A SEPARATE PAGE 8 FOR EACH APPLICANT.
CHILD’S NAME ___________________________________________________
PREFERRED NAME _____________________________________________
RACE _____________________________________
PRIMARY INSURANCE COVERAGE: PRIVATE _____ TITLE XIX (MEDICAID) _____ TITLE XXI (HEALTHWAVE) _____
MEDICARE _____
SECONDARY INSURANCE COVERAGE: PRIVATE _____ TITLE XIX (MEDICAID) _____ TITLE XXI (HEALTHWAVE) _____
MEDICARE _____
MILITARY _____ I.H.S. _____ **ATTACH A COPY OF THE INSURANCE CARD.
MILITARY _____ I.H.S. _____
**ATTACH A COPY OF THE INSURANCE CARD.
INSURANCE PLAN #/CASE # __________________________________________________________________________________
INSURANCE PLAN #/CASE # _______________________________________________________________________________________________________
INSURANCE COMPANY ______________________________________________________________________________________
INSURANCE COMPANY ___________________________________________________________________________________________________________
INSURANCE POLICYHOLDER __________________________________________________________________________________
INSURANCE POLICYHOLDER _______________________________________________________________________________________________________
PRIMARY DOCTOR’S NAME _________________________________________________ ___________________________________
SPECIAL CONDITIONS:
ADDRESS __________________________________________________________________________________________________
POTENTIAL OR SUSPECTED DISABILITY _____________________________________________________________________________________________
PHONE NUMBER ___________________________‐__________________________________‐______________________________
DIAGNOSED DISABILITY _________________________________________________________________________________________________________
DENTAL INFORMATION
**ATTACH A COPY OF THE INSURANCE CARD.
DIAGNOSIS DATE ______________________________________________________________________________________________________________
INSURANCE PLAN ____________________________________________________________________________________________
POTENTIAL OR SUSPECTED ALLERGIES _____________________________________________________________________________________________
INSURANCE POLICY HOLDER ____________________________________________________________________________________
REACTION ___________________________________________________________________________________________________________________
PRIMARY DENTIST’S NAME ____________________________________________________________________________________
DIAGNOSIS DATE _____________________________________________________________________________________________________________
ADDRESS ___________________________________________________________________________________________________
IN ORDER TO MEET ALL LEGAL REQUIREMENTS, I HEREBY AUTHORIZE KICKAPOO HEAD START / EARLY HEAD START
PHONE NUMBER _________________________________‐_____________________________________‐______________________
PROGRAM STAFF, TO GIVE CONSENT FOR ANY AND ALL NECESSARY EMERGENCY MEDICAL CARE FOR MY CHILD: THIS
ANY OTHER MEDICAL CONDITIONS (CONCERNED OR SUSPECTED):
AUTHORIZATION IS VALID FOR UP TO ONE YEAR FROM THE DATE OF NOTARIZED SIGNATURE.
CHILD’S NAME_________________________________________ DOB______________________
ANY SOCIAL SERVICE CONCERNS:
PARENT’S SIGNATURE __________________________________ DATE_____________________
STATE OF KANSAS
COUNTY OF _______________________________
EMERGENCY CONTACTS:
BEFORE ME, THE UNDERSIGNED AUTHORITY, ON THIS DAY PERSONALLY APPEARED
____________________________________________ KNOWN TO BE AS THE PERSON WHOSE NAME IS SUBSCRIBED
PRIMARY CONTACT
ABOVE, AND ACKNOWLEDGED TO ME THAT HE/SHE EXECUTED THE SAME FOR THE PURPOSE THEREIN EXPRESSED.
1)________________________________________ RELATION______________________________
SWORN AND SUBSCRIBED BEFORE ME THIS _________ DAY OF ____________, 20_________.
ADDRESS ________________________________________________________________________
________________________________________NOTARY PUBLIC AND FOR ______________ COUNTY, KS
PHONE NUMBER __________________________________________________________________
MY COMMISSION EXPIRES ____________________________________
SECONDARY CONTACT
2)________________________________________ RELATION_____________________________
(SEAL)
ADDRESS _______________________________________________________________________
PHONE NUMBER _________________________________________________________________
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