Welcome to NACT Head Start Program

Welcome to NACT Head Start program. Our program is designed to provide you and your child with comprehensive education services. These services include developmentally appropriate educational experiences, health, and mental health services, and a safe and secure environment. We provide family support services by offering parent training workshops on various topics, resources and referral information and opportunities to be involved in the Head Start program.

Head Start services are provided to families that meet the income guidelines as well as families of children with disabilities.

EACH CHILD’S APPLICATION MUST HAVE THE FOLLOWING DOCUMENTS BEFORE IT CAN BE PROCESSED

o  Completed application

o  Birth certificate

o  Child’s social security card

o  Current immunization record

o  Current physical (to include lead screening and Hgb/Hct.) ( form attached)

o  Dental exam ( form attached)

o  Verification of income ( 12 Months)

o  For Foster parents or Legal Guardians official documentation

AN INCOMPLETE APPLICATION WILL DELAY ENROLLMENT

NACT Head Start does not enroll on first come basis; your child’s application will be prioritized according to the criteria list attached.

** If assistance is needed to obtain any of the items listed above please contact us at 918-446-7339

Native American Coalition of Tulsa

Criteria List

This form must be completed at time of application to the program to be considered for enrollment. An X should be placed by any of the situations described below that apply to anyone in your immediate family. This information will be use to prioritize your eligibility into the NACT Head Start Program.

1.____ Homeless (this includes sharing a house with others, living in motels, hotels camping grounds, in

shelters or cars)

2.____ Single Parent family

3.____ Child raised by someone other than parent (grandparents, other family members)

4.____ Foster child

5.____ Child was previous enrolled in Head Start (or Early Head Start)

6.____Family is receiving TANF, or SSI

7. ____ Substance abuse, domestic violence in the home

8.____ Court ordered or referral from another agency (provide proof of referral)

9.____ Family member has health issues, or disability

10.___ Crisis in family during past year (incarceration, fire, death, etc)

11. ___ Child has a professionally diagnosed disability (provide proof)

12.___ Child suspected of having a disability (what type?) ______

13. ___Other, describe ______

______

Parent/ Guardian Signature ______

Please mark which site you are requesting:

____ West Campus ____ Park View ____ Sand Springs

____ Mark Twain ____ Prattville ____ Glenpool

NACT Head Start

Enrollment Application

Please fill out completely and accurately. All information will be kept confidential. Completing this application does not guarantee that your child will be accepted. Applications must meet all eligibility guidelines and will be prioritized by greatest need.

Child’s Name: ______Nickname______

Date of Birth ______SSN:______Gender: M ____ F____

Address: ______City______Zip Code______

Mailing Address if different ______

Telephone: Home: ______Cell______Message______

Race: circle all that apply:

Caucasian Native American African American Hispanic Asian Other: specify______

Ethnicity (mark one) ______Hispanic or Latino ______Non- Hispanic or Latino

English Proficiency: None Poor Moderate Proficient

Other language spoken: ______None Poor Moderate Proficient

Insurance: (Please fill out one):

Medicaid #______Sooner Care#______

Private Name & # ______None ______

Has child been previously enrolled in Head Start or other development Program? ______

If yes, what program______

Has your child been diagnosed with any disability? (Please circle one) Yes No

If yes, please provide information and documentation.

Family Information:

Child lives with: ( ) both parents ( ) mother only ( ) father only ( ) foster

( ) someone other than parents, relationship ______

Is your Family receiving any of the following: Please circle all that apply

TANF SSI Disability SNAP Subsidized Housing WIC

Is daycare used for child? Yes No If yes, is daycare subsidized? Yes No

Housing: (circle one) Rent Subsidized Live with relatives Homeless

Is there at least one member of your family in the United States Military? Yes No

I certify that the information provided in this application is accurate and truthful to the best of my knowledge

Parent Signature ______Date______