Early Childhood Enrollment Application - Kootasca Community Page 4

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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
Middle Name
Last Name
First Name
Race
Additional Family
Additional Family
Suffix
□
□ White
□ Black
□Sr □___
Male
□
Indian/
American
Alaskan
□
Mom’s 1
st
Dad’s 1
st
Name
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
st
Language - English Other____
1
□Separated □Widowed
□
□Medicare □HMO
Active Duty
□Foster Child □Other_______
□Divorced □Living Together
□Indian Health □Private □None
nd
Language - Other____ English
2
□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
□ Yes
Associate degree
highest grade completed _______
Average Weekly Work Hrs_________
□ No
□ No
High school/GED
Bachelor Degree
Unemployed, Seeking Employment
Some College
Graduate/professional degree
Unemployed, NOT
Seeking Employment
Degree Pursuing
__________________________________
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
Middle Name
Last Name
First Name
Race
Additional Family
Additional Family
Suffix
□
□ White
□ Black
□Sr □___
Male
□
Indian/
American
Alaskan
□
Mom’s 1
st
Dad’s 1
st
Name
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
st
Language - English Other____
1
□Separated □Widowed
□
□Medicare □HMO
Active Duty
□Foster Child □Other_______
□Divorced □Living Together
□Indian Health □Private □None
nd
Language - Other____ English
2
□Never Married
Date of Birth
Last 4 Digits of
US Citizen?
Disability?
Highest Level of Education
Employment
If less than high school diploma
Trade School
Social Security #
□ Yes
□ Yes
Associate degree
highest grade completed _______
Average Weekly Work Hrs_________
□ No
□ No
High school/GED
Bachelor Degree
Unemployed, Seeking Employment
Some College
Graduate/professional degree
Unemployed, NOT
Seeking Employment
Degree Pursuing
__________________________________
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
Additional Family
Suffix
□
□ White
□ Black
□Sr □___
Male
□
Indian/
American
Alaskan
□
Mom’s 1
Dad’s 1
st
st
Name
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
□MA-IM Care/MN Care
□Spouse □Daughter □Son
st
Language - English Other____
1
□Separated □Widowed
□Medicare □HMO
□
Active Duty
□Foster Child □Other_______
□Divorced □Living Together
□Indian Health □Private □None
nd
Language - Other____ English
2
□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
□ Yes
Associate degree
highest grade completed _______
Average Weekly Work Hrs_________
□ No
□ No
High school/GED
Bachelor Degree
Unemployed, Seeking Employment
Some College
Graduate/professional degree
Unemployed, NOT
Seeking Employment
Degree Pursuing
__________________________________
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
Additional Family
Suffix
□
□ White
□ Black
□Sr □___
Male
□
Indian/
American
Alaskan
□
Mom’s 1
st
Dad’s 1
st
Name
Name
Female
□Asian
□ Hispanic
□Hawaiian/
Pacific Islander
Vet Status
Additional Family Member Language
Relationship to
Marital Status
Health Insurance Type
Head of Family (HOF)
□Single □Married
□Yes □No
□Spouse □Daughter □Son
□MA-IM Care/MN Care
st
Language - English Other____
1
□Separated □Widowed
□
□Medicare □HMO
Active Duty
□Foster Child □Other_______
□Divorced □Living Together
□Indian Health □Private □None
nd
Language - Other____ English
2
□Never Married
Date of Birth
Last 4 Digits of
US Citizen?
Disability?
Highest Level of Education
Employment
If less than high school diploma
Trade School
Social Security #
□ Yes
□ Yes
Associate degree
highest grade completed _______
Average Weekly Work Hrs_________
□ No
□ No
High school/GED
Bachelor Degree
Unemployed, Seeking Employment
Some College
Graduate/professional degree
Unemployed, NOT
Seeking Employment
Degree Pursuing
__________________________________
Early Childhood Application Form 2016-2017
Revised 10/30/2015

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