Community Action of South Eastern West Virginia

Head Start/Early Head Start Enrollment Application

Applicant (Pregnant Woman or Child) and Family Information

Applicant Last Name: / First Name: / Preferred Name (Nickname):
Race: B = Black/African-American W = White A = Asian BM=Biracial/Multiracial N = American Indian or Alaskan Native P = Native Hawaii/ Other Pacific Islander O=Other Ethnicity: I. Hispanic or Latino Origin  II. Non-Hispanic/Non-Latino 
Applicant’s Social Security #: / Sex: (circle one) F = Female M = Male / Date of Birth:
Address: / City/State:
Zip Code: / Phone:  Home  Message: / Other Phone:
Physical Address:
Parental Status: (circle one) O = Single Parent T = Two Parents F = Foster N = Not Child’s Parent D=Joint Custody same household two separate households
Number in Family: / Number of Children in Family: ______by Age: 0-3______4-5______
(EHS) Pregnant Mothers: Expected Due Date ______
How did you hear about Head Start?  family  friend  media
 other:______/ Does child/applicant have a disability or special needs?  Yes  No  Suspected
Were you referred to Early Head Start/ Head Start?Yes  No If yes, please specify ______/ Does applicant currently have a diagnosed medical condition? Yes  No If yes, please state condition: ______

Marital Status of Parents: Single, Married, Separated, Divorced, Widowed Child Resides With______

Please circle

Are there any custody restrictions? Yes or No If so, describe: ______

______

(All areas below must be completed if applicable)

Father / Mother / Legal Guardian/Step Parent
(Other than Father or Motxur)
Name______
Address (If different from child’s)
______
______
Date of Birth______
Home Phone #______
Cell Plone #______
Do you live in the home? Yes or No
` Please Circle
Unemployed, Employed, Trainiog, School
Circne the one that best describes your situation.
Emðloyar______
Work Phone #______
Highest Level of Education______
Ethnicity: Hispanic or Non-Hispanic
Circle One
Rice______/ Name______
Address (If different from child’s)______
______
Date mf Birth______
Home Phone #______
Cell Phone #______
Do you live in the home? Yes or No
$ Please Circle
Unemployed, Emphoyed, Training, School
Circle the one that best describes your situation.
Employer______
Work Phone #______
Highest Level of Education______
Ethnicity: Hispanic or Non-Hispanic
Circle One
Race______/ Name______
Address (If different from child’s)
______
______
Date of Birth______
Home Phone #______
Cell Phone #______
Do you live in the home? Yes or No
Please Circle
Unemployed, Employed, Training, School
Circle the one that best describes your situation.
Employer______
Work Phone #______
Highest Level of Education______
Ethnicity: Hispanic or Non-Hispanic
Circle One
Race______

Please mark all that applies to your family situation:

Family Type / Housing / Household Language / Ethnic Group / Do you receive any of the following?
__Both parents w/child
__Single Male Parent
__Single Female Parent
__Foster Care/ Grandparent
__Other______
Please Specify / __Homeless
__Own
__Rent
__HUD or Low-income
Housing
__Lack of stable residence
__Shelter / __English
__Spanish
__French
__German
__Other______
Please Specify / __Asian or Pacific Islander
__African American (Black)
__American Indian
__Caucasian (White)
__Hispanic
__Other______
Please Specify / __TANF
__Food Stamps
__WIC
__SSI
__Social Security
__CHIPS
__Medicaid Card

Others Living in the Home:

Name Date of Birth Relationship Name Date of Birth Relationship

______

______

Medical Information:

Does the child have any allergies? Yes or No If yes, please specify______

Does the child have a suspected or diagnosed disability? Yes or No If yes, specify______

If yes, does the child have a current IEP? Yes or No If yes, for what______

Does the child currently take any medications? Yes or No If yes, what______

Name of Health Insurance Provider______Policy #______

Physician’s Name______Dentist’s Name______

Emergency Information:

Emergency contacts

Name / Relationship / Phone #(s) / Authorized to pick-up child

Family Income: (Required)

How many people are in your family unit? ______

Mark the answer that best describes your family’s yearly income. (This includes but is not limited to: wages, Social Security Benefits, Unemployment Benefits, TANF Benefits, child support, Veteran’s Benefits, Worker’s Compensation.)

___ Under $10,000.00 ___$10,001.00 - $15,000.00 ___$15,001.00 - $20,000.00 ___$20,001.00 - $25,000.00 ___$25,001.00 - $30,000.00 ___$30,001.00 - $40,000.00 ___$40,001.00 - $50,000.00 ___Over $50,000.00

** MUST INCLUDE COPY OF BIRTH CERTIFICATE AND INCOME (IF NO INCOME PLEASE PROVIDE A WRITTEN STATEMENT TO VERIFY)**

To the best of my ability and knowledge, the information on this form is correct. I understand that if any of this information changes, such as address, phone, employment information or income, number of persons in the family, etc., I am to notify the program immediately.

______

Signature of Applicant/ Parent or Guardian Date

Please Mark Below Your First, Second, and Third Choice for Attendance:

CASE WV Head Start LocationsCASE WV Early HeadStart LocationsOther

Glenwood Head Start ______Glenwood Early Head Start Center _____Spanishburg ____

Lashmeet Head Start _____Bluefield Early Head Start ______Oakvale Elementary_____

Thorn Street Head Start Center _____ Early Learning Center-Cumberland Heights Kennedy Center Head Start ______Early Learning Center- Silver Springs _____

Bluefield Ave. Head Start Center ____ Princeton Child Development Center _____

Learning Tree House _____

I Imagination Station ____ Mother Goose _____

For Head Start Students please attach copy of income verification, and birth certificate.

When application is completed, please fax or mail to:

CASE WV EARLY HEAD START/ HEAD START

307 Federal Street, Suite 323

BluefieldWV24701

Attn: Family/ Community Partnership Coordinator

(304) 487-5740- Fax

(304) 487-5770

NOTE: No Transportation is provided for Early Head Start