Application Miami-Dade Community Action And Human Services Department Head Start / Early Head Start Family Information Page 3
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Miami-Dade Community Action and Human Services Department
Head Start / Early Head Start
Family Information
Primary Adult Name: ____________________________________
Birthday: ________ ___________________________
Eligible Child Name: ______________________________________
Birthday: _____________________________________
General Information:
Living Address:
City
State
Zip
County
Mailing Address (if different):
City
State
Zip
Phone Number
Home, Work, Cell, E-mail
Primary
Notes
□
□
□
Number in Household ______
Num. in Family ______
Total Num. of Children ______
Num. Age 0-3 ______ Num. Age 4-5 ______
(Living with Child)
(Supported by the income of parent or guardian)
Parental Status:
Primary Language at Home:
Center Applying for:
Natural/Adopted/Stepparent Foster
Grandparent Niece/Nephew
□
□
One parent
Two parents
□
□
Family Income – Time period income based on:
Previous 12 Months
Last Calendar Year
□
□
□
□
□
□
□
□
□
TANF
Yes
No
Formerly
SSI
Yes
No Food Stamps/SNAP
Yes
No
WIC
Yes
No
WIC ID _______________
Income Source
Frequency
Weekly Monthly
Every 2 weeks Annually Twice a month
Non-Agricultural Earned Income (i.e. wages, tips)
Weekly Monthly
Every 2 weeks Annually Twice a month
Agricultural Earned Income (i.e. wages, tips)
Weekly Monthly
Every 2 weeks Annually Twice a month
Public Assistance, Welfare (i.e. TANF, AFDC)
Weekly Monthly
Every 2 weeks Annually Twice a month
Social Security Pension / Retirement
Weekly Monthly
Every 2 weeks Annually Twice a month
Supplemental Security Insurance (SSI)
Weekly Monthly
Every 2 weeks Annually Twice a month
Foster Care/Adoption Subsidy
Weekly Monthly
Every 2 weeks Annually Twice a month
Unemployment Compensation
Weekly Monthly
Every 2 weeks Annually Twice a month
Child Support/Alimony
Weekly Monthly
Every 2 weeks Annually Twice a month
Other Unearned Income
Income Notes:
Emergency Contacts: (please complete carefully)
Name:_________________________________________________________
Relationship:
__________________________________________
Address:_____________________________________ City:___________________ Zip: _____________ Phone #: ________________
Phone #: ________________
Name: _________________________________________________________
Relationship: __________________________________________
Address:_____________________________________ City:___________________ Zip: _____________ Phone #: ________________
Phone #: ________________
Medical / Dental Providers: (please complete carefully)
*
*
Yes
Doctor:
No
(Staff Use Only) Referred to:_______________________________________
Date: ______________ Referred by:__________________
Doctor Name:________________________________________
Address:_____________________________________ Phone #:________________
*
*
Yes
Dentist:
No
(Staff Use Only) Referred to:_______________________________________
Date: ______________ Referred by:__________________
Dentist Name:________________________________________
Address:_____________________________________ Phone #:________________
Miami Dade CAA Head Start / EHS – December 2012
Page 1
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