RESA 8 Early Head Start/Head Start Pre-K Family Demographics
Date: ____/____/___
Child’s Last Name: ______FCP Worker: ______
Family Composition
List Adults (Head of Household first), then children oldest to youngest. Put a * by the Head Start enrollee.
Name / DOB / Gender / Race / Language:Primary/
Secondary / Highest Grade / School/Training
Employment Type & Location / Relationship to enrollee / Health Concerns
Parents’ English Ability (Check all that apply.): __ very well __ well __ not well __ not at all
Child’s Ethnicity: __ Caucasian __ Black __ Hispanic __ Asian __ other ______
Primary Occupational Status (If two-parent family, please check all that apply:
__ Full – time (more than 34 hours per week) __ Unemployed
__Part-time__With past employment history
__Seasonal-Non Agricultural __ With no previous job experience
__Seasonal- Agricultural __ Unable to work due to disability
__ Employed and in school __ Active Military
__ Training program with salary __ Veteran
__ Training program without salary __ Retired
__ Other __ Homemaker
__ In School
__ Towards high school diploma/GED
__ Towards trade/business qualification
__ Towards college degree
__Towards postgraduate degree
__ In school and employed
__Other
Types of Services or Financial Assistance Received (mark all that apply):
__ No services received
__ Medical financial assistance (i.e. Medicare/Medicaid) __ Unemployment insurance
__ Food Stamps__ Public housing assistance
__ Public assistance/Welfare (i.e.TANF/AFDC)*__ Emergency program assistance
__ WIC__ LIEP
__Supplemental Security income (SSI)__ Child Support / Alimony
__ Foster Care/Adoption subsidy__ Other: ______
Housing Payment Arrangement:
__ Own House__ Exchange Services for housing__ Receive subsidized housing
__ Rent Housing__ Make no payment for housing__other: Specify ______
Type of Housing:
__ House __ Mobile home/trailer__ Homeless/no housing__ Migrant housing
__ Apartment__ Community shelter__M/Hotel room__ Other:
Family currently has means of transportation: __ Yes __ No
Primary mode(s) of transportation used (mark all that apply):
__ Private vehicle (car, truck, van)__ Public transportation (bus, subway, taxi)
__ Friend or relative’s vehicle__ Other: ______
Child to be cared for by someone other than the head of household in addition to participating in Head Start:
__ Yes __ No
Day Care Provider (s) (mark all that apply):
__ Older sibling 12 -__Adult non-relative in non-relative’s home
__ Older sibling 12 +__ Childcare center
__ Relative__ Other: ______Adult non-relative in child’s home __ Not arranged yet
Do you receive a subsidy for child care; example – Mountainheart? __ Yes__ No
SM/AK 3/17