Application for Head Start and Early Head Start

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					                                          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?
                                                                                                                 Yes No
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
Foster Parent/s
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
this child.

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