Southern Oregon Child and Family Council
Application for Head Start and Early Head Start
Visit our website at WWW.SOCFC.ORG
1001 Beall Lane, P.O. Box 3697, Central Point, OR 97502 (541) 734-5150 Fax (541) 734-2279
Josephine County Office: 223 SE M Street, Grants Pass, OR 97526 (541)472-4851 Fax (541) 472-4855 *
Child's Name: Male Female Child's Date of Birth Child's Social Security Number Pregnant Moms:
Due date of
Is this a high risk pregnancy?
Parent/Guardian Name Parent/Guardian Name
Mailing Address Living Address Same as Mailing
(1) Phone (2) Phone (3) Phone Email Address
Home Cell Message Work Home Cell Message Work Home Cell Message Work
Please list everyone living in your household
Name How is this person related to the child Date of birth Does this person provide financial
(for example: Parent, Step Parent, support for the family?
Foster Parent, Brother, Sister)?
Are you able to bring your child to school? Yes No Are you able to pick your child up from school? Yes No
Although we cannot provide bussing for all children, we will try and help you get your child to school
Child's daytime address if different What language do you speak most How did you hear about Head Start/Early Head Start?
from living address often? Sibling attended Head Start/Early Head Start An ad or article in
English the paper A flyer in local business Referred from an agency
Spanish Received an application from local grade school Friend/Family
Other; please list Radio TV Doctor/Dentist Office Other______________
Please mark all sources of household income in the past 12 What is your current housing type?
months. Living with friends or family due to lack of money
Employment Unemployment TANF/Cash Grant Living in a hotel, camp trailer, or shelter
Adoption Subsidy Child Support Financial Aid Other, please describe
Supplemental Security Income
Please continue on other side
Here at Head Start/Early Head Start, our mission is to serve children and families with the highest
need. The information you give will be treated as confidential and only used to determine need. If
you would like to speak with an enrollment specialist about your family please call us at 734-5150.
Child lives with: If the child lives with parents, Are you receiving an adoption Has the child been involved
1 Parent are either of the parents: subsidy for this child? in a DHS Child Welfare case
2 Parents Between age 19 and 21 Yes No in the last year?
Grandparent/Relative Age 18 or younger Yes No
Is your child on an IFSP? No Yes Please describe any concerns Has your child been
if yes, please mark the diagnosed disabilities for which your child you have with your childs evaluated, received, or is
is receiving Early Intervention/Early Childhood Special Education development or behavior? receiving special services
(EI or ECSE) services: _________________________ from an other agency or
Speech/Language disorder _________________________ professional?
Developmental delay _________________________ No
Emotional/behavioral disorder ________________________ Mental Health Services
Orthopedic impairment Has your child been referred for Other:________________
Vision these concerns?
Hearing No Yes
Other Health Impairments
Some other things we consider when selecting students Child's sibling attended or attends Head Start or Early
Parent does not have friends or family in the area to turn to yyyyHead Start
yyyywhen they need help and support Family attended LISTO
Child's parent is recovering from substance abuse, or in The child attended Head Start or Early Head Start in
yyyytreatment yyyyanother place
Child's parent is incarcerated Parent is enrolled at RCC Redwood Campus
Child's parent is disabled Child has a health issue, please describe:
Child's parent has a diagnosed mental illness
A member of the househould has a serious health issue
A member of the household has recently died
Domestic violence is/was occurring in the household
Is there anything else about your child or family you would like us to know when considering you for Head Start or Early Head Start?
Head Start/Early Head Start offer a Full Day Full Year option for working families who qualify. If eligible, would you like to be
considered for Head Start or Early Head Start's all day/year round childcare program? Yes No
If yes, are you receiving Employment Related Day Care (ERDC) through DHS? yes No
Please describe the typical work schedule for each parent/guardian living in the household:
Work Hours Days of the week Total Weekly Hours
I understand this is an application ONLY and does not guarantee enrollment in the program. All information is confidential. I also
understand that I must keep Head Start/Early Head Start informed of any change of address or phone number. I am legally responsible for
Parent/Guardian Signature _____________________________________________ Date ___________________
In order for us to consider your child for enrollment we must see proof of your income and the child's date of
birth. If you are unable to get this documentation, or have any questions or concerns, please call our office
at 734-5150 and an enrollment specialists will help.
SOCFC provides equal opportunity and access to all services and/or employment to every person. SOCFC does not discriminate on the basis of race, religion, gender,
ethnicity, cultural background, age, disabilities or sexual preference, or any other legally protected class or status. For further information regarding compliance under
this policy contact the Human Resources Director who serves as the Title VI, VII, IX, and Section 504 Compliance Coordinator at (541) 734-5150, TTY/TDD 1-800-8