Beaucare Head Start
BeauCARE Head Start Complete one application for each eligible child
308 Martin Luther King Drive For assistance with application call 337.460.1500
Phone 337.460.1500
Fax 337.460.1500
ELIGIBILITY REQUIREMENT INFORMATION SHEET
Please return this page with your application and documentation!
Thank you for applying for BeauCARE Head Start. In order to determine your child(ren) eligibility, you must provide the items listed below with your application. The completion of this form should not be considered a formal acceptance into the program, but one of the steps in completing the eligibility process.
We accept applications throughout the school year for anyone who is interested in enrolling into the BeauCARE Head Start program.
Application Date: / Sex: Male Female
Child’s Legal Name (Last) (First) Date of Birth
Race / Does the child have a disability or special need? If YES, does your child have an IFSP / IEP?
[ ] Yes List______[ ] No [ ] Suspected [ ] Yes through______[ ] No [ ] in process
Child’s Address City Zip Code: State:
Primary Phone #: ( ) Other Phone #: ( )
FAMILY INFORMATION
PARENT / GUARDIAN # 1 / PARENT / GUARDIAN # 2
Name:
Date of birth
Gender / [ ] Male [ ] Female / [ ] Male [ ] Female
Address
Phone Number
Marital status: / [ ] Divorced [ ] Married [ ] Re-Married
[ ] Separated [ ] Single [ ] Widowed / [ ] Divorced [ ] Married [ ] Re-Married
[ ] Separated [ ] Single [ ] Widowed
Parental Status / [ ] Single Parent – Mother figure only
[ ] Single Parent – Father figure only
[ ] Single Parent – Mother living with partner
[ ] Single parent – Father living with partner
[ ] Two parent family
[ ]Joint custody (2 parents, 2 separate houses)
[ ] other relative ______/ [ ] Single Parent – Mother figure only
[ ] Single Parent – Father figure only
[ ] Single Parent – Mother living with partner
[ ] Single parent – Father living with partner
[ ] Two parent family
[ ]Joint custody (2 parents, 2 separate houses)
[ ] other relative ______
Highest Grade Completed / [ ] below 4th [ ] 6th [ ] 7th [ ] 8th [ ] 9th
[ ] 10th [ ]11th [ ] 12th but did not graduate
[ ] GED [ ] High School Graduate
[ ] Some College [ ] Associates Degree
[ ] Bachelor’s Degree [ ] Advanced Degree / [ ] below 4th [ ] 6th [ ] 7th [ ] 8th [ ] 9th
[ ] 10th [ ]11th [ ] 12th but did not graduate
[ ] GED [ ] High School Graduate
[ ] Some College [ ] Associates Degree
[ ] Bachelor’s Degree [ ] Advanced Degree
Relationship to child: / [ ] Biological Mother [ ] Biological Father
[ ] Biological Sister [ ] Biological Brother
[ ] Biological Grandmother [ ] Step Father
[ ] Biological grandfather [ ] Step mother
[ ] Foster [ ] Adoptive mother
[ ] Adoptive Father [ ]Legal Guardian
[ ] other (explain)______/ [ ] Biological Mother [ ] Biological Father
[ ] Biological Sister [ ] Biological Brother
[ ] Biological Grandmother [ ] Step Father
[ ] Biological grandfather [ ] Step mother
[ ] Foster [ ] Adoptive mother
[ ] Adoptive Father [ ]Legal Guardian
[ ] other (explain)______
In job training or school / [ ] Yes, Full-Time [ ] Yes, Part-Time
Where?
What are you studying? / [ ] Yes, Full-Time [ ] Yes, Part-Time
Where?
What are you studying?
Please Mark all that apply: / [ ] Work Full Time [ ] Work Part Time
[ ] Disabled [ ] Homemaker [ ] Retired
[ ] Receiving job training
[ ] seeking employment / [ ] Work Full Time [ ] Work Part Time
[ ] Disabled [ ] Homemaker [ ] Retired
[ ] Receiving job training
[ ] seeking employment
Pay checks received from work: / [ ] Weekly; [ ] biweekly,
[ ] twice a month [ ] monthly / [ ] Weekly; [ ] biweekly,
[ ] twice a month [ ] monthly
Housing
Housing Situation
Please check the correct housing situation for the applicant:
[ ]Home / Apartment that I rent or own
[ ]Temporarily living with a family member or friend due to loss of housing, economic hardship or similar reason
[ ]Subsidized housing ( Section 8, HUD, Rent Assistance)
[ ] Staying in emergency or transitional shelter/ housing
[ ] living in a motel because I cannot afford housing
[ ] Living in my car
[ ] Other: ______
FAMILY MEMBER INFORMATION
List ALL family members living in the household who are financially supported by parent / guardian of the applying child. These family members are those whom are related by blood, marriage, or adoption. INCLUDE THE APPLICANT AND PARENT/GUARDIAN NAMES FROM ABOVE. If there are more household members than will fit, please write the information on the back of this document
Name of Person / Birth Date / Relationship / Family Member / Gender
Applicant / [ ]Adult [ ] Child / [ ] Male [ ] Female
[ ]Adult [ ] Child / [ ] Male [ ] Female
[ ]Adult [ ] Child / [ ] Male [ ] Female
[ ]Adult [ ] Child / [ ] Male [ ] Female
[ ]Adult [ ] Child / [ ] Male [ ] Female
[ ]Adult [ ] Child / [ ] Male [ ] Female
[ ]Adult [ ] Child / [ ] Male [ ] Female
OTHER INFORMATION
Does anyone in your family receive SSI
[ ]YES [ ] NO / Does your family receive TANF
[ ]YES [ ] NO
Do you receive child support [ ]YES [ ] NO / Do you receive Social Security Benefits [ ]YES [ ] NO
Do you receive Veterans Benefits [ ]YES [ ] NO / Do you receive Retirement [ ]YES [ ] NO
Do you receive Unemployment [ ]YES [ ] NO / Do you receive any Scholarships or Grants [ ]YES [ ] NO
Is the applicant a foster child? [ ]YES [ ] NO
Does your family receive WIC / [ ]YES [ ] NO / Does your family receive Food Stamps? ( ) Yes ( )No
Does your child have a doctor? / [ ]YES [ ] NO / Name of Doctor:
Does your child have a dentist? / [ ]YES [ ] NO / Name of Dentist
Does your child have health insurance? / [ ]YES [ ] NO / If so with whom: (ex. Medicaid, TriCare, Blue Cross)
STOP
Do not write in this area – FOR OFFICE USE ONLYDate Application Received by Office: ______Received by: ______
Age of child as of Sept. 30: ______yrs ______months
Child Plus Data Entry Date: ______Initials of staff who input data: ______
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