Head Start & Early Head Start Enrollment Application Form Page 2
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1
2First & Last Name of
How Related to Applicant
Date of Birth
Sex
Notes
Children in Home
1
Applied Child
2
3
4
5
6
INFORMATION
At Least one parent/guardian is a member of the United States military on active duty
Yes
No
At least one parent/guardian is a veteran of the United States military
Yes
No
What type of transportation do you use? Check one.
Car
Bus
Walk
Other
If available, is a Head Start school bus needed?
Yes
No If needed, why?
Children with special needs may receive priority for Head Start enrollment. Your disclosure of this information is strictly
Voluntary.
1. Does your child have a disability? ________ (If no, please go to question #6)
2. Type of special need or disability
_____________________________________
3. Has the disability been professionally diagnosed?
(If yes, at what age ________?
By whom? ____________
4. Does the child have an IFSP/IEP?
________
5. Is the child receiving special services for the disability? ______________________
6. In your opinion, does your child have a special need that has not yet been diagnosed?
If yes, please explain: ______________________________________________________________
Certification: I certify that this information is true. If any part is false, my participation in this agency’s program may be
terminated. I also understand that the information in this application will be held in strict confidence within the agency and is
accessible to me during normal business hours.
Children and pregnant mothers that are determined to be eligible for the Early Head Start program are eligible
until the child turns 3 years old (4 years old if the child is in family child care).
Applicant Signature :
Date:
TO BE COMPLETED BY STAFF
Initial Enrollment
Center Name:
Family ID:
First Day Child
Program Year:
Attended Class (Entry):
Child ID:
Acceptance Status (circle):
Program Type:
EHS
EHS-CCP
Program Option
Accept
Denied
HS
First 5
LIFT
Home Base
Full Day
Part Day
Income Eligibility (select only one):
Categorical Eligibility (select one):
CD 9600 date: ________
Income (below federal poverty guidelines)
Over-income
Homeless
Foster Care
Documents Verified (select as many as apply):
Check Stub
W2
Written Statement from
Documents Verified (select one):
First date of subsidized
Employer
service
TANF/CalWORKs
SSI
Unemployment
Foster Care Reimbursement
:______________
Document of no income
Other _______________________
Statement from homeless services provider
Other _______________
$______________________
Total Annual Income:
st
Birth Verified By
Birth Certificate
Passport
Age by September 1
:
Months at time of Enrollment
Medi-cal Card
(EHS & EHS-CCP only):
Other
__________________
Verifying Staff Member
Print Name
Date:
Signature:
Verifying Staff Member
Print Name
Date:
nd
Signature (2
year) :
nd
Parent confirms eligibility for 2
year of Head Start based on Head Start Regulations (1305.7(c))
In-person Interview
Phone Interview:
________________________________________________________________________
______________________________________________________
______________________________________________________
Provide reason for phone interview in lieu of in-person interview
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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