Head Start & Early Head Start Enrollment Application Form
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1
2HEAD START & EARLY HEAD START ENROLLMENT APPLICATION
THE CHILD’S INFORMATION
FIRST 5
EHS-CCP
EHS
HS
LIFT
Child’s Legal Name
First
Middle Initial
Last
Child’s Place of Birth (City, State)
Child’s DOB (mm/dd/yyyy)
Sex
Child’s Ethnicity
Child’s Race
Child’s Primary Language
Child’s Secondary Language
Pacific Islander
Black
White
English
Spanish
English
Spanish
Latino
Biracial/ Multi
Hispanic
Nat. Amer.
Vietnamese
Vietnamese
Other _________
Yes
No
Asian
Other_____________
Other _________
THE CHILD’S HOUSEHOLD FAMILY INFORMATION
Latino
Yes
1 Primary adult name
Primary Language if different
Secondary Language if
?
No
from child
Different from child
Race
Latino
Yes
2 Secondary adult (if any)
Marital Status:
Parental Status:
?
No
Single
Married
One parent
Two parents
Race
Divorced
Separated
Foster parent
Residential Address
Mailing Address (if different from Residential Address)
City
State
Zip Code
City
State
Zip Code
CA
Primary Phone Number (including area code)
Other Phone (including area code)
Current Housing:
Rent
Own
Homeless
Total in
Total # of Children
Family
Other______________
If not homeless, date you moved in_______________
Is your child related to a Preschool Services Department Employee?
Previous Housing:
Rent
Own
Homeless
No
Yes
Employee Relationship to child:_______________
Other_______________
Email Address:
ELIGIBILITY INFORMATION
Family Receives :
Check one if applicable:
Does Family Have Medical Insurance?
SSI
YES
NO
Medi-cal
IEHP
Healthy Families
Yes
No
TANF/CalWORKS YES
NO
Emergency
Other
Does family receive WIC?
Does Family Receive
Does Child Have Dental Insurance?
Yes
No
Yes
No
Yes
No
CalFRESH (EBT)?
How did you hear about us?
Community Event
Flyer/Poster
School District
Community Partner Referral
Former Parent
Other Head Start
State Preschool
Facebook
Local Community Agency Referral
Public Advertisement
Family Friend
Mailings
Public Service Announcements (TV/Radio)
Other ___________________________________
PARENT AND/OR GUARDIAN
INCOME SOURCE
Employment
Disability
1
Unemployment Benefits
Other_________
Employment
Disability
2
Unemployment Benefits
Other_________
PRENATAL INFORMATION
N/A
Pregnant before Enrollment
First Pregnancy
Expected delivery date: _______________
ADULT HOUSEHOLD FAMILY MEMBER INFORMATION
(Please only include adults in the household supported by the income of the parent.)
(Enter Primary Adult First)
Date of
How Related to
Sex
Education
Employment
Attending
First & Last Name
Level
Birth
Applicant
Status
school/training
1
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3
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Z:\Website Submissions\2016-05-31 New Applications\Head Start-Early Head Start Enrollment Application English.doc Revised. 4/18/16
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