FCP.04
Head Start and Early Head Start
CHILD APPLICATION
Program Type: Early Head Start(Serving pregnant moms and children ages 0 to 3)
Head Start(Serving children that are 3 or 4 years old on or before September 1st)
1. Child’s Name:______ M F Date of Birth: ____/____/______
First M.I. Last
2. Parent or Current Guardian: ______Date of Birth: ____/____/______
First Last
3. What is the applying child’s relationship to the parent or guardian listed above?
Circle one: Foster GrandchildNatural/Adopted/ Step Niece/Nephew Other, describe: ______
4. List any additional family members who are living in the household who are (1) supported by the child’s parent(s) or guardian(s) income; and (2) related to the child’s parent(s) or guardian(s) by blood, marriage, or adoption; or (3) the child’s authorized caregiver or legally responsible party.
First / Last Name Date of Birth Relationship to Parent/Guardian (listed above)
___/___/_____
______/___/_____
______/___/_____
______/___/_____
___/___/_____
___/___/_____
___/___/_____
5. Home Address: ______
Street Apt / Trailer# CityState Zip Code
6. Mailing Address:______Street/PO Box City State Zip Code
7.Contact Numbers: Home Phone: ______
Name : Cell: ______Work: ______Email: ______
Name : Cell: ______Work: ______Email: ______
Message Phone: Name: ______Phone: ______Relationship to Family: ______
8. Primary language spoken in the home:
Do you need an interpreter? Yes No Do you have an Interpreter? Yes No
Interpreter name: ______Interpreter phone:______
Head Startmay provide transportation services for preschoolers, as needed.
1. Would you like your child to ride the bus to and from school? Yes No
2. If yes, where would you like the bus to pick up and drop off your child?
Busing Address: ______Street Apt / Trailer# City
3. If busing is not available, are you able to provide transportation for your child?Yes No
The following information will help to prioritize your child’s application and determine any additional services that may be needed.
It will be kept strictly confidential. If you have questions about your child’s development, or would like help in completing this section (questions 1-5), please call 1-800-841-2867 ext. 110 to speak with an Early Childhood Specialist.
1. Do you have concerns about your child’s development? No (skip to question 3) Yes
Please give us a brief description of your concern:
2. Has your child ever been evaluated regarding these concerns?NoYes
If yes, who completed the evaluation?
Please submit a release of information.
3. Has your child ever participated in an early childhood development program, such as Early Intervention, anotherHead Start, or
other Preschool Program, etc? No Yes, please specify: ______
- If yes, has your child ever been on an *IFSP or IEP (Individual Family Service/Education Plan)? No Yes
*AnIFSP or IEP is a written treatment plan that maps out services your child will receive, as well as how and when
these services will be administered. It describes your child’s specific needs and goals.
4. Who is the applying child currently living with? Check one box. Both Parents
Single Mother / Unmarried Couple
Single Father / Unmarried Couple
Relatives
Non-relatives
5. Where are you and your family currently staying:Check one box.
Living in my own apartment/home that I rent or own.
Sharing the housing of another family (i.e., doubling up) due to loss of housing, economic hardship or similar reason.
Living in a motel, hotel, camp trailer, or campground because we cannot afford or find affordable housing.
Staying in an emergency or transitional shelter.
Living in a vehicle; in an abandoned building, the park, or any other facility without running water/electricity.
6. Were you referred to this program from another agency? NoYes, please specify:
How did you hear about Head Start/EHS?______
7. Have you or your family members experienced an event that has greatly impacted your life inthe past year, such as divorce, loss of loved one, moving, new family member, etc? No Yes
If yes, please explain:
Please note that before your application can be considered for enrollment, you must:
Submit a complete, signed application.
Submit verification of child’s birth.
Submit proof of income for the previous 12 months or last year (see attached checklist).
Submit a consent form to release information to/from your School District / Early Intervention.
Verify your application information with RUCD staff through a brief interview.
I understand that intentionally providing false information may result in ineligibility or termination from the program. I certify that the application information and verifications I have submitted are true and accurate.
Parent Signature: Date of application:
Locate the nearest Head Start or Early Head Start Program @ to return this application OR submit it to our main office: RUCD Head Start, 150-A West Main Street/PO Box 508, Wellington UT 84542.
Rvsd 9/2015