Start a Taxi Business in Deschutes County - PDF - PDF

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					Dear Head Start Applicant,

Thank you for your interest in Head Start. Head Start is a free comprehensive preschool program that serves children
from income eligible families. In order to qualify for the 2007-2008 school year, a child must be born between 9/2/2002
and 9/1/2004.

Please complete this application and turn it along with income verification in as soon as possible. Space is limited.
    You can submit the application in person, or by mail to 2303 SW First Street, Redmond, Oregon 97756, or fax it to
    (541) 504-5725.

The information on this application will help NeighborImpact to determine your child’s eligibility for Head Start and
prioritize your application. All information supplied will be held in strict confidence. If you feel uncomfortable filling
out any portion of this application and would like to discuss your situation with a Head Start staff member, please call the
Paula Smith, Family Partnership Specialist at 548-2380 ext. 129.

In order to process your child’s application, please attach 12 months proof of income with your Head Start application.
Please include all of the following that apply- for both Parents/Guardians living in the home:
        • All of Last Year’s W-2 forms or Last Year’s 1040 tax statement
        • A December pay stub with the year to date (only if you worked there for entire year)
        • Child Support payments received – for the last 12 months
        • Unemployment payments
        • TANF number and a letter from a DHS caseworker
        • For a child in Foster care, a letter from the caseworker
        • SSI award letter
        • Scholarships/Grant award letter
Please send in copies of your income verification. All income documents you send in with your child’s application will be
shredded to protect your privacy. If you have any questions regarding proof of income, please call me at 548-2380 ext.
143. I am also available by e-mail at

Please note, this application does not ensure enrollment. You will be notified regarding the status of your application as
soon as possible.

Thank you,
Wendi Skala
Record Keeping and Monitoring Support/ Enrollment
                                                                                            For office use only: C _________ OI ______ I ______

        Head Start APPLICATION 2007-2008
 The information on this application will help NeighborImpact to determine your child’s eligibility for Head Start and prioritize your
 application. All information supplied will be held in strict confidence. If you feel uncomfortable filling out any portion of this
 application and would like to discuss your situation with a Head Start staff member, please call the Paula Smith, Family Partnership
 Specialist at 548-2380 ext. 129.
Legal Name of Child (First Name, Middle Name, Last Name)                                     Nickname                         Birthdate:              Gender:
                                                                                                                                                      □ Male □ Female
Home address:                                                                                City                             State    Zip Code       County

Child lives with: □ 1 Parent    □ 2 Parents    □ Legal Guardian(s)    □ Foster parent(s)   □ Dual Custody      □ Other (please explain)
1. Parent/ Legal Guardian                                                                                                     Phone #:

Mailing address (if different than above)                                                    City                             State    Zip Code       County

2. Parent/ Legal Guardian                                                                                                     Phone #:

Mailing address (if different than above)                                                    City                             State    Zip Code       County

Primary language spoken in the home:                                                         Child’s primary language:

How well does the child speak English?                                            In which language would you prefer to receive written materials?
                                  □ Well      □ Not Well    □ None
Would you like your child to ride the bus to and from school if available?        Does your child attend childcare? If yes, please list name of childcare provider/center:
                                  □ Yes            □ No
Address for Bussing:                                                                         City, State, Zip Code            County           Phone for Bussing Address:

Please check the box and initial in space provided if family is currently                           Is the child receiving services through ECSE (Early
receiving services from the following agencies?                                                     Childhood Special Education) or EI (Early Intervention)
                                                                                                    and is currently on an IFSP? Yes_______ No_______
□   _____ Department of Human Services                                                              In order to serve my child better, I give permission for
                 □ Self Sufficiency Program □ Child Welfare Program                                 NeighborImpact Head Start to contact ECSE (Early
                 □ TANF □ ERCD □ Food Stamps                                                        Childhood Special Education).
□ ____ Bethlehem Inn
□ ____ Ready, Set, Go                                                                               Signature: ___________________________________
□ ____ Mt. Star Relief Nursery
□ ____ Even Start                                                                                   Date: ____________________________________
□ ____ COBRA (Central Oregon Battering and Rape Alliance)
□ ____ Safety Net
□ ____ Kids Center
I give permission for NeighborImpact Head Start to contact agencies initialed
above on my behalf.
Signature: ________________________________ Date: ________________
 Please let us know if you have a concern or if your child currently has a diagnosed medical or developmental condition (Please mark
 all that apply and provide name of doctor or professional you are current working with on the issue.)
 ADHD/ADD _____________________               Concern □         Diagnosis □       Diagnosed by _______________________________
 Autism ________________________              Concern □         Diagnosis □       Diagnosed by ______________________________
 Communication disorder _________             Concern □         Diagnosis □       Diagnosed by ______________________________
 Developmental delay _____________            Concern □         Diagnosis □       Diagnosed by ______________________________
 Diabetes _______________________             Concern □         Diagnosis □       Diagnosed by ______________________________
Eczema (requiring prescription) _____         Concern □                       Diagnosis      □       Diagnosed by ______________________________
Emotional/behavioral disorder ______          Concern □                       Diagnosis      □       Diagnosed by ______________________________
Hearing Impairment __________________ Concern □                               Diagnosis      □       Diagnosed by _______________________________
Heart Condition _____________________ Concern □                               Diagnosis      □       Diagnosed by _______________________________
Orthopedic impairment ________________ Concern □                              Diagnosis      □       Diagnosed by _______________________________
Food Allergies or Special Diet Needs _____ Concern □                          Diagnosis      □       Diagnosed by _______________________________
Seizure disorder (requiring medication ____ Concern □                         Diagnosis      □       Diagnosed by ______________________________
Severe tooth decay
more than 3 missing, filled or decayed teeth)Concern □                        Diagnosis      □    Diagnosed by ______________________________
Traumatic brain injury _________________ Concern □                            Diagnosis      □    Diagnosed by ______________________________
Visual impairment ____________________ Concern □                              Diagnosis      □    Diagnosed by ______________________________
Physical impairment __________________ Concern □                              Diagnosis      □    Diagnosed by ______________________________
Asthma (requiring medication)                 Concern □                       Diagnosis      □    Diagnosed by ______________________________
        Is asthma currently being treated yes___ no___                    Date of last occurrence__________________________________________
Other (please explain) _________________      Concern □                       Diagnosis □         Diagnosed by ______________________________

Please use the key provided below and place the number which best describes all family members in the same
household for education, race and ethnicity in the table below:
Education Level*                                              Race*                                                               Ethnicity:
     1) 0-8th grade                                                 1) American Indian or Alaskan Native                               1) Hispanic
     2) 9-12th grade                                                2) Asian                                                           2) Non Hispanic
     3) High School Diploma or GED                                  3) Black or African American
     4) 12+ some college                                            4) Native Hawaiian or Other Pacific Islander
     5) Associate Degree                                            5) White
     6) Bachelors                                                   6) Bi-racial/Multi-racial
     7) Post Grad                                                   7) Other
     8) Vocational or Grad School
                                                                                      ***Use       Health                                   Person      ***Use       ***Use
                                                                                      above        Insurance                                living in   above        above
 Household Members List all including you                             Relationship    Key for      Type (OHP,       Disabled    Veteran     home        key for      key for
 (First Name, Middle Initial, Last Name)         Sex    Birthdate     to child        Education    Private, None)   Y/N         Y/N         Y/N         Race         Ethnicity

***If there are additional family members please document on a separate sheet of paper.

Is anyone in the household a farm worker? Yes____ No ____                            If yes, farm worker status?           Seasonal           Migrant             Farmer
***The definition of a farm worker is one who works in connection with cultivating the soil, raising or harvesting any agricultural commodity, or in catching, netting,
handling, planting, drying, packing, grading, storing or preserving in its non manufactured state any agricultural commodity.
Diagnosed medical issues currently affecting any of your immediate family members living in the home.
(Please mark all that apply and list who is affected)
         Cancer _______________________________________________________________________________________________
         Stroke ________________________________________________________________________________________________
         Heart Disease __________________________________________________________________________________________
        Chronic Obstructive Pulmonary Disease (COPD) ___________________________________________________________
        Developmental disability_________________________________________________________________________________
        Mental Disorder (Depression, Bi-polar, Anxiety disorder, Schizophrenia) ______________________________________
        Physical Impairment ( Hearing or Vision) __________________________________________________________________

Environmental issues currently affecting the immediate family (mark all that apply)
□    Child abuse or neglect                                          □ Parole/Probation of parent or household member
□    Family is homeless ( includes families living temporarily                 □ Divorce/Separated (within 24 months)
        in shelters, hotels, or vehicles; or moving frequently       □ Court Orders for Protection
        between the homes of relatives or friends)                   □ Death in the immediate family (within 24 months)
□    Lack of Transportation prevents meeting basic needs             □ Domestic violence
□    Parental substance abuse                                        □ Disaster / tragedy/severe trauma
□    Family without food in the past month                               please explain___________________________________
□    Incarceration of parent

Family Type:                                      Housing:                                 Number of times the family has
    Two parent family                                Own                                   moved in the past 12 months:
    Single mother                                    Rent                                      Family has not moved
    Single mother living with partner                Homeless                                  Once             Twice       Three
    Single father                                                                              Four or more times
    Single father living with partner             Type of Housing:                         Has the family been homeless in past
    Foster family                                    House                                 12 Months (Including currently
    Grandparents raising child(ren)                  Apartment                             homeless):
    Other relative(s)                                Hotel/Motel room                          Yes      No (skip to next question)
    Other family type                                Mobile Home/Trailer                   Length of time homeless:
    Teen Parent                                      Migrant Housing                           Less than 1 month      1-3 months
     (currently 18 years old or younger)             Community Shelter                         3-6 months     More than 6 months
                                                     Other: _____________________
Family Currently Has Means of Transportation:            Yes     No (skip next questions)
        Primary mode(s) of transportation used (mark all that apply):
                   Private vehicle (car, truck, van)             Public transportation (BAT, Dial A Ride, taxi)
                   Friend’s or relative’s vehicle                Other: _________________________
        Family has alternate means of transportation if primary mode(s) are unavailable: Yes                 No
Job Status: Please select appropriate box for parent or guardian of the child.
Primary Occupation Status:
   Paying job                                      In job training program
   Full-time - Mother Father                                   Training program with salary - Mother Father
   Part-time - Mother Father                                   Training program without salary - Mother Father
   Seasonal-Non Agricultural -Mother Father                    Unemployed
   Seasonal-Agricultural - Mother Father                      Homemaker - Mother Father
   Employed and in school - Mother Father                     Retired - Mother Father
                                                              Unable to work due to disability - Mother   Father
   In school
    Towards high school diploma/GED- Mother Father          Towards trade/business qualification- Mother Father
    Towards college degree- Mother Father                   Towards postgraduate degree- Mother Father
    In school and employed- Mother Father
Is the family currently working with any of the following programs in NeighborImpact?
□ Nancy’s House             □ COHSP (Healy Heights or Crook Apartments)              □ IDA (Individual Development Account)
□ Home Ownership Center □ Emergency Services (LEAP, Rental Assistance, Brown Bag)
□ Child Care Resources      □ Bend Aid
The information received will be used to evaluate my situation and plan for and coordinate services for me and my family. I authorize
NeighborImpact programs to share and exchange information in the Head Start application about me or my family and my
circumstances with one another.

Signature_________________________________________________________________ Date___________________

PLEASE ATTACH PROOF OF INCOME for the last 12 months or last calendar year.
I certify that the information provided in this application is accurate and truthful to the best of my knowledge, and authorize
Head Start to obtain income verification from DHS SSP if needed.

                                                                     /           /
Parent/Guardian Signature                                                Date
                                                                     /           /
Parent/Guardian Signature                                                Date

“The U.S. Department of Agriculture (USDA) and the State of Oregon prohibit discrimination in all USDA programs and activities on the
basis of race, color, national origin, sex, religion, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of
Civil Rights, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5965 (voice
and TDD). USDA and the State of Oregon are equal opportunity providers and employers”

NeighborImpact does not discriminate against any person on the basis of race, color, national origin, disability or age of admission, or
participation in its programs services and activities, or in employment. For further information about this policy, or to arrange for an
accommodation, contact Human Resources/Section 504 Coordinator, phone number 541- 548-2380 Ext. 115,
State Relay 711.

                                                         OFFICE USE ONLY

Family Size _____ Income_________ 12 mo____ Cal Yr.____ Age 9/1 ____ USDA ____________
Income Verification Used: ________________________ Eligible □     Over □  _______%
County:    Crook       Deschutes    Jefferson
Income Source
             No Income                   Pension                  TANF                             General Assistance
             SSI                         Unemployment             Social Security                  Farm Worker
             Employment only             Employment + any other source                             Other

STAFF SIGNATURE:____________________________________ DATE:________ HSFIS:_______

STAFF SIGNATURE:____________________________________ DATE:________

Classroom ___________________________________                 Total Selection Criteria point’s __________

Referred by:_________________________________________Agency__________________________

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