Early Childhood Enrollment Application - Kootasca Community (Page 3 of 4) in pdf

Early Childhood • Enrollment Application

FC Homeless MFIP SSI

Date App Rec’d________ Age by Sept 1 _____

_____

yrs

IRScore___________ RFScore___________

← ← Office Use only → →

Annual Gross Income Verified

TAPP Only Early Head Start Head Start Invest Early 0-3 Invest Early PS Other____________

_________

by_____________ Date

S T U D E N T

A P P L I C A N T

I N F O R M A T I O N

□Jr

Last Name

First Name

Middle Name

Student Applicant

Suffix

Race

Student

□Sr □___

□ White

□ Black

□

Male

□

Indian/

American

Alaskan

Mom’s 1

Dad’s 1

Name

□

□Asian

□ Hispanic

Female

□Hawaiian/

Pacific Islander

Street Address

P.O. Box

City

County

State

Zip Code

Student

Date of Birth

Last 4 Digits of

Is Student a

Student has a

Language

Health Insurance Type

Student

Social Security #

US Citizen?

Disability?

- English Other______

□MA-IM Care/MN Care □Medicare

□Yes

Language

□ No

□HMO □Indian Health □Private □None

- Other______

English

Language

□Yes □ No

Does Student have an IEP?

Does Student receive mental health services?

Mom/Guardia

Mom/Guardian

Dad/Guardian

n Home/Cell #

Work #

Home/Cell #

Work #

Additional Contact Person Name

Phone Number

Relationship to Student Applicant

Student Applicant Concerns (please place an “x” by ALL concerns)

Premature/Low Birth Weight High Risk Pregnancy Birth Defects/Chronic Illness Medical Speech/Language Behavior

Separation Anxiety Child with no Group Experience Development Concerns Other_________________________________________

H E A D

O F

F A M I L Y

I N F O R M A T I O N

(HOF)

□Jr

Middle Name

Last Name

First Name

Race

HOF

Suffix

□

□ White

□ Black

□Sr □___

Male

□

Indian/

American

Alaskan

□

Mom’s 1

Dad’s 1

Name

Female

□Asian

□ Hispanic

□Hawaiian/

Pacific Islander

Relationship to Student Applicant

Marital Status

Vet Status

Housing Type

Family Type

HOF

□Single □Married □Separated

□Own □Rent □Homeless

□Single Person □Single Parent/Female □Single

□Yes □No

□Mom/Guardian □Dad/Guardian

□Widowed □Divorced □Living

□Shelter □Living with

Parent/Male □Two Parent Household □Foster

□Foster Parent

□

Together □Never Married

Active Duty

□Grandparent/Child □Non-Custodial Care Giver

Extended Family

□Other_____________

Disability

Date of Birth

Last 4 Digits of

HOF Highest Level of Education

Health Insurance Type

HOF

Citizen?

If less than high school diploma

Trade School

Social Security #

□MA-IM Care/MN Care

□ Yes

Associate degree

highest grade completed _______

□Medicare □HMO □Private

High school/GED

Bachelor degree

□

□ No

Yes

Some College

Graduate or professional degree

□Indian Health □None

□ No

Degree Pursuing

__________________________________

HOF Employment

Does Family Receive CCAP Funds?

Language

Email Address

HOF

Average Weekly Work Hrs___________

Language English Other_________

(Child Care Assistance Program

Unemployed, Seeking Employment

thru Itasca County)

Language Other__________

English

□Yes □ No

Unemployed, NOT Seeking Employment

Family Concerns (please place an “x” by ALL concerns)

English is not primary language Medical/Health Issues Living with extended family Adult Disability History of Chemical Abuse

Recent Divorce/Loss Homeless/Transitional Transportation Unemployment Teen Parent Parent absent for extended period

A D D I T I O N A L

F A M I L Y

M E M B E R S

D E M O G R A P H I C S

□Jr

Last Name

First Name

Middle Name

Race

Additional Family

Suffix

□

□ White

□ Black

□Sr □___

Male

□

Indian/

American

Alaskan

□

Mom’s 1

Dad’s 1

Name

Female

□Asian

□ Hispanic

□Hawaiian/

Pacific Islander

Relationship to

Marital Status

Vet Status

Additional Family Member Language

Health Insurance Type

Head of Family (HOF)

□Single □Married

□Yes □No

□Spouse □Daughter □Son

□MA-IM Care/MN Care

Language - English Other____

□Separated □Widowed

□

□Medicare □HMO

Active Duty

□Foster Child □Other_______

□Divorced □Living Together

□Indian Health □Private □None

Language - Other____ English

□Never Married

US Citizen?

Disability?

Date of Birth

Last 4 Digits of

Highest Level of Education

Employment

If less than high school diploma

Trade School

Social Security #

□ Yes

Associate degree

highest grade completed _______

Average Weekly Work Hrs_________

High school/GED

Bachelor Degree

□ No

Unemployed, Seeking Employment

Some College

Graduate/professional degree

Unemployed, NOT

Seeking Employment

Degree Pursuing:

_________________________________

Please insert Additional Family Members on Back. Thank you.

I certify there are a total of _______ members of my household dependent upon the income I submitted.

I certify the above information is true and correct and that Early Childhood staff may verify the information.

Date

Parent / Guardian Signature

Early Childhood Application Form 2016-2017

Revised 10/30/2015

Early Childhood Enrollment Application - Kootasca Community Page 3

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