I/T___3-5 yr. old___1st yr.__2nd yr.__3rd yr.__Mfld__Vspr__Biron__WR__Nekoosa___HB__ Entered______Date______
Wood CountyHead Start Inc
Preschool & Infant/Toddler Program
APPLICATION
2017 – 2018 Program Year
“ALL INFORMATION IS KEPT CONFIDENTIAL”
If you are pregnant and filling this application out for yourself go to the Mother-to-Be Information section.
Child’s Legal Name (Last) ______(First) ______
Date of Birth: ______Sex: Female Male Race: ______
What Language does child speak? ______Interpreter needed: Yes No
Child lives with: ______Total number in family: ______
Does your child attend a public school or other educational program? Yes No
If yes, what program? ______
Check any concerns you have about your child’s overall health or development?
Learning Health Behavior Speech/Language Hearing Vision Other:______
How did you hear about the Head Start program? ______
Living Address: ______
StreetCityStateZip
Mailing Address: ______
StreetCityStateZip
Telephone #: ______Cell phone #:______
Email address: ______What county do you live in: ______
MOTHER-TO-BE INFORMATION
Name (Last) ______(First) ______
Date of Birth: ______Estimated Due Date: ______Marital Status: ______
*Race: ______Language: ______
Last School Grade Completed: ______Current Employer/School: ______
Number of Hours @ Work/School: ______
My Living Addressis: My own residence With relatives/friends
My own residence with relatives/friends Other: ______
Do you own or rent: Own Rent Other: ______
Housing Type: Apartment House Duplex Mobile Home Shelter Other: ______
Parent Military Deployment: Yes No
Parent Status (in household) One Two Legal Guardian Foster
Mother’s Name (Last) ______(First) ______
Address (if different from child’s): ______
StreetCity/StateZip
Telephone #: ______Cell phone #:______
Date of Birth: ______Marital Status: ______
*Race: ______Language: ______Last School Grade Completed: ______
Employer: ______Number of Hours Worked: ______
Father’s Name (Last) ______(First) ______
Address (if different from child’s): ______
StreetCity/StateZip
Telephone #: ______Cell phone #:______
Date of Birth: ______Marital Status: ______
*Race: ______Language: ______Last School Grade Completed: ______
Employer: ______Number of Hours Worked: ______
Guardian (if applicable)Name (Last) ______(First) ______
Relation to Child: (check one) Foster Aunt Grandparent Other: ______
Date of Birth: ______Marital Status: ______
*Race: ______Language: ______Last School Grade Completed: ______
Employer: ______Number of Hours Worked: ______
Family Type:
Two Parent Family (includes Step-Parents) Single Parent Family (mother only)
Single Parent Family (father only) Single Parent Family (mother only) living w/partner
Single Parent Family (father only) living w/partner Other relative(s)
Foster Family Other family type
First and Last Name / Date of Birth / Sex / Relationship to Child(ie. Brother, Sister, Uncle)
(Check all that apply)
WIC Supplemental Security Income (SSI)
Food Stamps Foster Care/Adoption Subsidy
Energy Assistance Housing Assistance
Childcare Assistance Wisconsin Works (W2)
Does the child you are applying for have medical insurance? Yes No
If yes: Medical Assistance/Badger Care Private
I give permission for Wood County Health Dept (Immunization Records, Lead and Hemoglobin), Wood County Head Start, Department of Human Services, Wisconsin Health Services and/or WIC to release/access information for my family to Wood County Head Start staff in order to verify services.
Applications cannot be fully processed without household income information & verification.
Parent Signature: ______Date: ______
Agency Use Only
Application Documentation: (Date and Initial each entry)
DOB Verified:______Source:______
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*Race is required for statistical purposes
January 4th, 2017