Application Miami-Dade Community Action And Human Services Department Head Start / Early Head Start Family Information (Page 2 of 6) in pdf

Office Use Only

(Checked upon receipt of Documentation)

MIAMI DADE COUNTY COMMUNITY ACTION AND HUMAN SERVICES DEPARTMENT

HEAD START/EARLY HEAD START

REGISTRATION REQUIREMENTS

Y N

Proof of Age :

Birth Certificate

EHS- Birth to age 3 years after September 1,

Passport

2013.

Notarized Affidavit of Age

HS -Children must be 3 or 4 years of age on or

Doctor’s statement (pregnant women)

before September 1, 2013, or no more than five

(5) years old after September 1, 2013)

Proof of parent’s/legal guardian gross income

Signed Income Form Tax 1040 with eligible child name

for the past 12 months or the last calendar

listed

year (2012).

W-2 forms

pay stubs (proof for the last 12 months)

Unemployment Compensation

Written statements from employers(letterhead)

Social Security Supplemental Income (SSI/TANF) printouts

Child Support Agency

Notarized Income Statement

Proof of Parent’s Identification

Driver’s license/Passport/ID from Homeless Shelter

State issued picture I.D.

Employer issued I.D.

Military ID

Driver’s license with address listed

Proof of Dade County Residency

State issued picture I.D. with address listed

Utility Bills (lights, phone, cable, etc)

Lease Rental /Mortgage Agreement

Proof of Disability

Individualized Educational Plan (IEP) /IFSP

Doctor’s Statement outlining concerns

Proof of Suspected Disability

Proof of Homelessness

Written Statement from Homeless Facility

Proof of Substance Abuse

Written Statement from Treatment Program

Proof of Domestic Violence

Written Statement from Domestic Violence Agency

Court Documentation (within the last year)

Proof of Student Status

Current transcript

Proof of Education eight grade and below

Written Statement from applicant/School Transcript

Written SSI recipient letter/Doctor’s statement

Proof of Parental Disability

Proof of Pregnancy

Written Medical Documentation (current)

Proof of Public Housing Residency

MDPHA Written Rental/Lease Agreement

Proof of Foster Caret/Legal Custody

Documentation from Foster Care Agency/ Court Award

Proof of Guardianship/Legal Custody

Documentation from Court System/ Court Award

Parents will certify that the information provided on the application and supporting documentation is true and correct and that all

parent(s)/legal guardian(s) income are reported. Deliberate misrepresentation of any information submitted may be subject to the

child being terminated from the program. An incomplete application and documentation will delay the enrollment process.

Documentation provided:

STAFF NAME/DATE_________________________________________________________

Documentation provided):

STAFF NAME/DATE_________________________________________________________

Documentation provided

STAFF NAME/DATE_________________________________________________________

Application Miami-Dade Community Action And Human Services Department Head Start / Early Head Start Family Information Page 2

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