Boyd CountyPreschool
Head Start & Kentucky Preschool
ECLC North – ECLC South – Catlettsburg
Main Office
1100 Bob McCullough Drive
Ashland, KY 41102
606-928-8001or 606-928-8022
Please fill out the attachedEnrollment Applicationin pencil!Return application with your family’sproof of incomefor 2012and child’s state birth certificate.Requirements listed in the box below do not have to be turned in with the Enrollment Application. These documentsmust be on file before your child can be placed in a classroom. If you need assistance in obtaining these documents please contact our office.
DOCUMENTS REQUIRED FOR ENROLLMENT
Keep this page as a reminder of requireddocuments
Boyd County Preschool/Head Start does not discriminate on the basis of age, color, creed, disability, parental status, marital status, race, national origin, religion, sex, actual or perceived sexual orientation, gender identification or socioeconomic or veteran status.
RELEASE & EMERGENCY CONTACT INFORMATIONPlease list first and last names of people who are allowed to pick your child up from school and theirrelationship to the child.
You do not need to include yourself in this list; parents and guardians are always called first.
Name
Relationship to child: / Address / Home Phone#
Cell# / Wk#
Name
Relationship to child: / Address / Home Phone#
Cell# / Wk#
Name
Relationship to child: / Address / Home Phone#
Cell# / Wk#
BUSING INFORMATION / Please be specific if your child will be picked up or dropped off by our bus system at a different location other than home address. / _____ Yes I will need busing for my
child to and from school.
_____ No busing needed. I will transport
my child to and from school.
_____ I only need busing in the morning.
_____ I only need busing in the evening.
Drop-off location:
Brief directions to your home:
Is any member of your family receiving: KTAP/TANFYes_____No__ SSI Yes______No______
Food Stamps Yes____No____ Child Subsidy Yes_____No_ WIC Yes______No______
2013 INCOME REQUIREMENT - Please include proof of Income for year 2012 with application.
Examples of Earned Income:Check Stub, Income Tax Forms, Written Statements from Employers, or Unemployment.
Examples of Public Assistance:Child Subsidy, KTAP/TANF, SSI, Kinship or Foster Care.
List amount and check below how you got paid in 2012: weekly, bi-weekly, monthly or yearly income.LIST FAMILY MEMBERS WHO:
Earned Income, received Child Support or Public Assistance for 2012. Please see examples above.
/LIST THE SOURCE OF:
Money or assistance you received in 2012.
Please see examples above.
/$ Amount
/ Wk
/Bi-
Wk
/ Month
/ = Yearly IncomePROGRAM INFORMATION TO BE FILLED OUT BY STAFF
School Year: / Program Code: / Center: / Class Age:Date Releases Signed: / Sibling Eligible Next Year: Y N / Family Income:
Parent Status:______PT______ / Disability:______PT______ / Income:______PT______
Other:______PT______ / Age:______PT______ / TOTAL ELIG. RATING:
Family has been verified as income eligible for our Head Start Program [ ] Yes [ ] No
Income Verified by: [ ] W-2 [ ]Tax Return [ ] Letter [ ] Check Stub [ ] KTAP [ ] SSI [ ]CHSUB [ ] OTHER
Birth Verified by: [ ] Certified Birth Certificate [ ] Hospital Birth Certificate [ ] Health Department Certificate [ ] Other
Verifying Staff Member: Date:
Certification: I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated. I also understand that the information in this application will be held in strict confidence and is accessible to me during normal business hours.
PARENT/GUARDIAN’S SIGNATURE:______DATE:______
PROGRAM INFORMATION TO BE FILLED OUT BY STAFFBoyd County Preschool
Head Start & Kentucky Preschool
PERMIT & AGREEMENT FORM
In regard to______
Child’s Name
I agree or permit:YesNo
1. That all records may be sent at the end of the year to my child’s receiving school.______
2. That, in case of an emergency, I give my permission to the staff to secure the needed
emergency medical care, if parents/guardians cannot be immediately contacted.______
3. That any picture taken of my child may be used in the newspaper, displays, bulletin
boards, webpage designs, or other types of educational publications.______
4. To allow staff to make home visits during the school year at my convenience.______
5. My child to accompany his/her class on all scheduled field trips. Teachers,
Instructional Assistants and Volunteers will care for my child during these trips.______
6. That my child will be in attendance in the program every day that he/she is able.______
7. That necessary information concerning my child may be released to the appropriate
agencies.______
(Boyd County Public Schools/Family Resource Centers & Boyd County Health Department)
8. To allow a board certified dentist, that partners with our program, to do a free visual______
dental exam for my child at school. I understand that no X-rays or treatment will be
done at this exam. The results of this visual exam will be sent to you.
* I give consent for my child to receive all screenings listed below. I understand that these services are deemed necessary by the Head Start Program and I will be informed of any results, which are not normal.
VISION SCREENINGHEIGHT & WEIGHT MEASUREMENT
DEVELOPMENTAL SCREENING LANGUAGE SCREENING
HEARING/SPEECH SCREENING PERSONAL/SOCIAL SCREENING
Please explain exceptions to the above items.
______
*I understand that this consent is valid for as long as my child is enrolled in Boyd County Preschool, the purpose of this consent form has been explained to me. I understand that the information provided above will remain strictly confidential.
I have the right to review records maintained on my family and to dispute or correct any information I feel to be incorrect.
______
Staff Signature Date Signature of Parent/Guardian Date
Boyd County Preschool/Head Start does not discriminate on the basis of age, color, creed, disability, parental status, marital status, race, national origin, religion, sex, actual or perceived sexual orientation, gender identification or socioeconomic or veteran status.