WESTMORELAND COMMUNITY ACTION – HEAD START & EARLY HEAD START

ENROLLMENT APPLICATION

------Date: ______

Child’s Name: ______Date of Birth: ______

Male / Female

Address: ______Mailing address: ______

Home Phone: ______Cell Phone: ______

Emergency Contact: ______Emergency Phone # ______

Email (optional): _______Family’s Primary Language: ______

HS Center Choice(1) ______(2) ______(3) ______EHS:___ Center___ Home-based

How did the family learn about Head Start?Central officeMiscellaneous Agencies

FlyersFriend or relative

In Program beforeOnline

Specific Agency ______

Advertisement on pizza box, hoagie, etc.

Through older child’s school

Other (please explain) ______

Child’s Race:CaucasianEthnicity:Hispanic Non-Hispanic

African-AmericanChild’s Health Insurance______

Asian Doctor’s Name: ______

Bi-Racial / Multi-Racial Dentist Name: ______

Other ______

Date of Birth / Relationship / Working Status / Education / Health Insurance
Parent/Guardian
Siblings
Others

RelationshipWorking StatusEducation

A – Bio MotherG – Foster FatherA – Full TimeA – Non High School Graduate

B – Bio FatherH – GrandmotherB – Part TimeB – High School / GED

C – GuardianI – GrandfatherC – SeasonalC – Some College / Technical School / Associates Degree

D – RelativeJ – StepmotherD – Not WorkingD – Bachelor’s Degree or Higher

E – SiblingK – StepfatherE – Disabled or Retired

F – Foster MotherL – OtherF – Student

Does this child have a diagnosed Special Need?

NoYes (Please Specify) ______

Suspected (Explain) ______

Does this child have a current IEP or IFSP?NoYes

Is there a Court Order limiting or restricting custody and/or access to the child?No Yes

**If there is a Court Order, a copy of the Order must be provided to Head Start.**

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Criteria – Check all that apply

___ Parent is under 25___ Parenting skills

___ Caretaker is 65 years +___ Domestic violence

___ Recent eviction or utility termination___ Housing in poor or sub-standard conditions

___ Parent/Guardian is disabled or terminally ill. Comment ______

___ Sibling with developmental or physical concern. Comment: ______

A parent is involved in:___ Drug___ Alcohol___ Mental Health Program___ Incarcerated

WCCB (Past or present involvement) Please explain: ______

If present, name of Case Worker ______

Other – Explain ______

What school district do you live in? ______

How many years have you been enrolled in Head Start? ______EHS______

Can you provide transportation for your child?NoYes

Current Agencies that the family is involved in: (Check all that apply)

___ TANF (Cash Assistance)___ Children’s Bureau___ Housing Assistance (HUD)

___ SNAP(Food Stamps)___ WIC___ Early Head Start

___ Energy Assistance___ Mental Health___ Medical Assistance

___ Parenting ___ Other ______

What are the family’s housing arrangements?

___ Rent___ Own___ Homeless

___ Live with others___ Other (explain) ______

February 8, 2016 – 3 pages