Change Of Status Template
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1EMAA-Head Start
(Rev. 7-15)
CHANGE OF STATUS
(Print Clearly)
Computer Use Only
Center Name__________________________ Class ____________
Date Edited _____/_____/_____
Edited by (initials)____________
Child’s Name ___________________________________________
Parent/Guardian ________________________________________
CHANGE INSURANCE/INFO
Insurance Drop/Add Date ______________________________
CHANGE ENROLLMENT STATUS
Type: Medicaid/Military/MC+/Private _____________________
Abandon Date______________ Reason __________________
Add Ins. Co. Name ___________________________________
Accept ___ Date: ___________ Class ____ Group_________
Drop Ins. Co. Name __________________________________
Enroll Date
______________ Reenroll Date: ____________
Effective Date _______________________________________
Entry Date __________________________
Termination Date___________ Last Date Attended _________
CHANGE OF CUSTODY TO (attach documentation)
Term. Reason _______________________________________
(NOTE: Provide Family Information for New Family)
Wait List: Yes/No Wait List at Center Name ______________
Foster Parent ____________ Natural Parent ______________
Daycare Enroll Date: ________ Daycare Term Date:________
Other _____________________________________________
Date of Change _____________________________________
TRANSFER/CHANGE –CENTER/CLASSROOM
Parent/Guardian Names for Labels
To Center __________________________________________
___________________________________________________
To Class ______ Last date in old classroom:_______________
First date in new classroom: ____________
PARENT STATUS
ONE
TWO
CHANGE NAME (if adoption, attach documentation)
FAMILY MEMBER
Child to ____________________________________________
(CIRCLE ONE) Add
Delete
Edit
Reason / Date:______________________________________
Adult (First and Last Name, Birthdate, SS#, Gender, Educ.
(If married, provide additional family member information)
Level, Employment Status)
Parent to __________________________________________
___________________________________________________
Reason/Date: _______________________________________
___________________________________________________
Children (First and Last Name, Birthdate, SS#, Gender,
CHANGE ADDRESS/PHONE
County ___________
Related to, How Related)
Living Address
____________________________________
___________________________________________________
____________________________________
___________________________________________________
Mailing Address
____________________________________
Add / Delete
____________________________________
CHANGE OF CONTACTS
Telephone
____________________________________
(CIRCLE ONE)
Add
Delete
Edit
Other
___________________________________
Name _______________________________________
Effective Date
____________________________________
Address _____________________________________
Phone
_________________________________
IMMUNIZATION UPDATE
Relationship __________________________________
Immunization Received _______________________________
______Emergency Contact ______Release To
Date Received ______________________________________
(CIRCLE ONE)
Add
Delete
Edit
INCOME CHANGE (circle one)
Name _______________________________________
(over-income re-evaluated OR re-verified for re-enrollment)
Address _____________________________________
Income Changed from $____________ to $_____________
Phone
_________________________________
Eligibility Points changed from ___________ to __________
Relationship __________________________________
Reason ____________________________________________
______Emergency Contact ______Release To
Date: ___________________ Initials __________________
Other
EMPLOYMENT STATUS (full-day)
_________________________________________________________
B- Full Time & Training
L- Part Time / Training
_________________________________________________________
F- Full Time
P- Part Time
_________________________________________________________
R- Retired or Disabled
S- Seasonally
_________________________________________________________
T- Training or School
U- Unemployed
PARENT/GUARDIAN PLACE OF EMPLOYMENT
Parent/Guardian: _____________________________________
Employer: ___________________________________________
Employer Address:_____________________________________
Employer Number: (___)____-______ Schedule: _____________
___________________________________________________
Staff Signature
Date
___________________________________________________
Parent Signature
Date
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