North Central State College/
The Ohio State University—Mansfield
Child Development Center
Early Head Start
2441 Kenwood Circle, Mansfield, Ohio 44906
Phone: 419-755-5600 * 888-755-4899 * Fax: 419-755-5605
Application
Child InformationLast Name: First: M.I.
Child’s Date of Birth or Due Date: / Child’s Race (check all that apply):
Asian
American Indian or Alaska Native
Black or African American
Native American or Pacific Islander
White
Some other race
More than one race
Other:
Child’s Gender: Male Female
Child’s Primary Language Spoken:
Have you been diagnosed with a high risk pregnancy?
No Yes
Is your child a transfer from an Early Head Start program?
No Yes Name of program:
Has your child been identified with a disability?
No Yes Suspected
Does your child have any physical or health conditions?
No Yes Describe: / Child’s Ethnicity:
Hispanic/Latino Non-Hispanic/Latino
Family Information
(A)Parent/Guardian Last Name: First:
Same household as child
(B)Parent/Guardian Last Name: First:
Same household as child
(A)Relationship to Child: / (B)Relationship to Child:
(A)Parent’s Date of Birth: / (B)Parent’s Date of Birth:
Mailing Address: City: Zip Code: County:
Cell: Cell phone carrier: Home Phone:
Email: / Student Status: NC State OSU-M High School
N/A
Employer:
Primary Language Spoken:
Number of children living in the household:
Please list names and ages:
Do you or any immediate family member have serious medical, physical, or mental health conditions, and/or alcohol/chemical dependency?
No Yes Describe:
Please indicate any of these which have occurred within the immediate family in the past year:
Child Abuse or Neglect Death of child’s sibling or parent Divorce
Domestic Violence Foster Care Placement Homeless
Parent Incarcerated Military Deployment Teen Parent
Single Parent Household Other relative raising child Pregnant Teen
Substance Abuse Issues
Family Income Information
For program purposes, family is defined as all persons living in the same household who are: (1) supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program, and (2) related to the parent(s) or guardian(s) by blood, marriage, or adoption. Also, income means total cash receipts before taxes from all sources.
Family Member (including self) / Amount / Gross Income Type / Income Source
Monthly Annual
Monthly Annual
Monthly Annual
Monthly Annual
Monthly Annual
Total Gross Annual Income / $
Please indicate the types of service or assistance currently receiving: (Mark all that apply)
Child Care Subsidy Food Stamps Financial Aid
Medicaid/Medicare SSI TANF/OWF
WIC No service/assistance received Other:
The Child Development Center provides early care and education in a full-year program operating Monday through Friday from 6:45 a.m. to 5:30 p.m. We offer full-time and part-time scheduling with a minimum enrollment of 12 hours and 2 days per week.
Early Head Start provides additional supports for expectant families, infants, and toddlers through center based or home based programming. The home-based program includes weekly home visits from an Early Head Start Family Visitor and two monthly group socializations.
Center Based:
I need Part-time (12 – 24.9 hours per week) or Full-time (25 – 53.75 hours per week) care.
Home Based:
I am interested in enrollment in the CDC’s Early Head Start home-based program: No Yes
I agree that the information provided is true and accurate. The CDC will not share this information with others and will use it to determine initial eligibility for enrollment into the Center and Early Head Start.
THIS APPLICATION WILL BE KEPT ON FILE FOR ONE YEAR FROM DATE SUBMITTED. PLEASE UPDATE INFORMATION AS NEEDED.
______
Parent/Guardian Signature Date
For Office Use Only
Date Received: Time Received: Initials:
1st Refusal Date: Date Application Removed: Initials:
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