Cabell, Lincoln, Mason and WayneCounties Early Head StartProgram

2015-2016 School Year Eligibility Application

Southwestern Community

County: ______Date of Application: ______Action Council Inc. Early Head Start

Site Location 1st Choice: ______Site Location 2nd Choice: ______

A. Enrollee Data: Child Resides with Whom?: ______Language Spoken in Home:______

Last Name / First Name / M.I. / Male/
Female / D/O/B / S.S. # / Race / Native Language / Birth Place
(City, State)
Physical Address: (Street, House/Box Number) / City / State / Zip Code / Mailing Address: (Street, House/Box Number) / City / State / Zip Code / Nationality

B. Parent or Guardian (Mother): Living in Home: _____Y_____N Relationship: ______

Last Name / First Name / (M.I) / D/O/B / Nationality / Race / Home Phone / Cell Phone
Physical Address: (Street, House/Box Number) / City / State / Zip Code / Mailing Address: (Street, House/Box Number) / City / State / Zip Code / Highest Level of Education
Employer / Occupation / Work Phone

C. Parent or Guardian (Father): Living in Home: _____Y_____N Relationship:______

Last Name / First Name / (M.I) / D/O/B / Nationality / Race / Home Phone / Cell Phone
Physical Address: (Street, House/Box Number) / City / State / Zip Code / Mailing Address: (Street, House/Box Number) / City / State / Zip Code / Highest Level of Education
Employer / Occupation / Work Phone

D. Directions to Home: ______

______

______

E. Educational History: Child is or was previously enrolled in any of the following

Child Care Location:______Date: ______Early Head Start Location: ______Date:______

Other:______Does child have a Birth to Three IFSP: _____Y _____N

*CONFIDENTIALITY STATEMENT: All information above is requested for the application process. All information must be completed to be considered. All information disclosed will be used only by those persons related to the program and who are on a need to know basis. Please initial each blank if you agree to the statement regarding the program.

___*Making application does not guarantee my child will be enrolled in the program.

___*Primary parent/guardian certifies that the information provided is accurate to the best of my knowledge.

___*My Child must attend the program regularly in accordance with the school district’s attendance policy.

___*Transportation to and from the program is not guaranteed.

___*My child will need to participate in a variety of screenings prior to the school year beginning and during the school year.

___*If enrolled, a current well child physical signed by a licensed physician is required along with immunizations that are current.

Parent/Guardian Signature Date Staff Signature Date

Cabell, Lincoln, Mason and WayneCounties Early Head Start Program

2015-2016School Year Eligibility Application

Southwestern Community

Action Council, Inc. Early Head Start Enrollee’s Name: ______

F. Household Composition: _____ Homeless _____ Own _____Rent (unsubsidized) _____Rent(subsidized)

_____Living with Friends or Family _____Transitional/Shelter _____ Other (______)

_____Anyone pregnant in the home Due date: ______Relationship to Enrollee: ______

______Medical Card if so Number:______Chips _____ Private Insurance _____ No Insurance

Total Family Members in Household: Total Adults:___ Total Persons Under 18:____Total in Home: _____

Email: ______

G. 1. Alternate Contact Name: ______Phone: ______

2. Alternate Contact Name: ______Phone: ______

H. Family Type: ____ Grandparents raising Child ____ Two-Parent Household _____ Single Parent _____ Foster Family

______Single parent family living with partner _____ Other Relatives Raising ______Other (Specify:______)

I. Children Data: List information for each child living in the household (do not include enrollee data):

Last Name / First Name / D/O/B / Male/
Female / Race / Native Language / Birth Place
(City, State)
1.
2.
3.

J. Adult Data: List information on all other adults living in household NOT including those listed above: (list additional on back)

Last Name / First Name / Relationship to Primary Parent or Guardian
1.
2.
3.

K. Income Data: Please complete the requested information below.

* The income information will be evaluated according to the “Income Guidelines” established by the United States Department of Health and Human Services to determine Head Start eligibility. All information will be strictly confidential. When submitting application attach the most current check stubs (for 12 months), W-2 Form, TANF verification, SSI verification, 1040 form, Child support, Foster Care, Unemployment Compensation, and/or affidavit of no income signed.

Do you currently receive TANF funds (Temporary Aid for Needy Families) or havePlease circle: YES or NO

you received these funds in the past twelve months?

Do You or any family member receive SSI payments (Supplemental Security Income)?Please circle: YES or NO

Do You or any family members receive WIC vouchers (Women, Infants and Children)?Please circle: YES or NO

Do you or your family members receive any other type of assistance?Please circle: YES or NO

If so, please list:______

Concerns about child’s overall health and development?Please circle: YES or No

If YES describe concerns: ______