Application Miami-Dade Community Action And Human Services Department Head Start / Early Head Start Family Information (Page 5 of 6) in pdf

Miami-Dade Community Action and Human Services Department

Head Start / Early Head Start

Eligible Child Information

Eligible Child (New Enrollee):

Last

First

Middle

Preferred / Nickname

Suffix

 Proof of age verified

Birthday

Gender

Source of age verification:

 M

 F

Medicaid Eligibility:

Race:

English Proficiency:

 None

 Poor

 Moderate

 Proficient

 Not Eligible  On Medicaid  Potentially Eligible

 Asian

Other Language Spoken:

 Black or African American

Medicaid Number:_________________________

 None

 Poor

 Moderate

 Proficient

 American Indian or Alaskan Native

□

 Native Hawaiian or other

Pacific Islander

Health Insurance Information:

Primary Adult Relationship to Child:

Custody

 White

 Foster*  Grandchild *  Biological  Adopted*

Name//Number:__________________________

 Step  Niece*

 Nephew *

Ethnicity:

 Other*



Other/Private Health Coverage(list name of provider):

(specify)____________________________________

 Hispanic or Latino Origin

□

________________________________________________

Secondary Adult Relationship to Child:

Custody

 Non-Hispanic or Latino Origin

 No Health insurance Coverage

 Foster*  Grandchild*  Biological  Adopted*

Nationality:________________________

 Step  Niece*

 Nephew*

Referral completed to:

 Other*

(specify)____________________________________

__________________________________________

* Legal court documentation is required to enroll child.

Kidcare Application Completed Date:_____________

Is there a current Order of Protection or No Contact order

Staff:_________________ Date: ______________

 Yes

 No

which concerns this child?

Special Needs/Disability:

(IEP):  Yes  No Date: ___

Miami Dade County Schools Diagnosed Disability Evaluation -Individualized Education Plan

Early Steps Program individualized Family Support Plan (IFSP): Yes  No  Date: ________

Yes  No  Date: ________

Professional Diagnosis (speech therapy, occupational, etc.):

 Yes

 No

(Medical Provider): Does the child have an ongoing source of continuous, accessible medical care?

 Yes

 No

(Dental Provider): Does the child have an ongoing source of continuous, accessible dental care?

Assistive Devices Used: Glasses Contact Lenses Crutches Walker Cane Wheelchair Braces Hearing Aides No Assistive Devices

No 

Yes 

Health Concerns:

Provide written documentation Describe: _________________________________________________________

Family Circumstances

: (please complete carefully)

Family Demographics:

Yes

Parental Status:

Yes



Place check

in appropriate box

Place check

in appropriate box

Documented Substance abuse

One Parent

Documented Domestic Violence

Two Parents

Documented Parent education <8

grade

Foster Parent

Documented Teen Parent <17 years old

Legal Guardian

Homeless

Length of time homeless: ___________

Family Services:



Agency:______________________________________

Place check

in appropriate box

Documented Pregnant Women

Medicaid/Medicare

Documented Public Housing Resident (MPHA)

Food Stamps/SNAP

Documented Parental Disability

WIC

Transition from Early Head Start to Head Start

Public Assistance/ Welfare

Documented Working Parent / Student

TANF/AFDC

Retuning Sibling(s) in Head Start/Early Head Start

Supplemental Security Income (SSI)

Documented –Referred for services by a child welfare agency

Documented Foster Program Referred

Miami Dade CAA Head Start / EHS – December 2012

Page 3

Application Miami-Dade Community Action And Human Services Department Head Start / Early Head Start Family Information Page 5

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