New Fayette Application Draft

STAFF ONLY Head Start/Early Head Start of Fayette County - Application (1)

Full application form

Staff Person Completing this application with the parent*
Overview Family Information
Number of Applying Children*
Please enter a number greater than or equal to 1.
Number in Head Start Family ***
**Definition of: Head Start Family Member means all persons living in the same household who are: Supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program, AND related to the parent(s) or guardian(s) by blood, marriage, or adoption; OR the child’s authorized caregiver or legally responsible party.
Complete for individuals identified as Head Start Family members, starting with applicant(s)
Adult or Child? Last First DOB Gender Relationship to Applicant Comments

To add additional people, click (+) below
Child's Information (1st child)
Program applying for:
- Head Start
- Early Head Start
- CCP
- New Participant
- Transition
- 3rd Year
Child's First Name*
Child's Middle Name
Child's Last Name*
Child's Gender
- Male
- Female
Child's Date of Birth*
Race*
Select more than one if necessary
If Other, please specify
Is English the child's primary language?
- Yes
- No
If yes, what is the child's English level?
- None
- Little
- Moderate
- Proficient
What is the child's primary language if English is not?
Level of child's primary language?
- Little
- Moderate
- Proficient
Is this child related to a HS / EHS employee?
- Yes
- No
If yes, name and relationship to the child
Is this child currently participating in the following?
- Pre-K Counts
- IU / Child Alert / Early Intervention
- N / A
- Unsure
Elementary School & district name which the family lives:
Have you applied with HS / EHS before for this child?
- Yes
- No
If yes, what year?
Is there a custody agreement regarding this child?
- Yes
- No
If yes, please provide / upload here
Max. file size: 50 MB.
Please provide / upload any Immunization records here
Max. file size: 50 MB.
Choose any of the following concerns the parent / guardian may have with the child
Any other concerns? ANY diagnostic documentation (IEP, IFSP, MH Evaluations) for any of the above concerns please list:
Please upload a copy of any diagnostic documentation (IEP, IFSP, MH Evaluation, etc.) if provided
Max. file size: 50 MB.
Head Start only: If the child's application is determined to be eligible for Pre-K Counts, I give permission for this information (contact, income, birth) to be shared with PIC Pre-K Counts Project Supervisor?
- Yes
- No
Head Start Only: Would you be interested in home-based service for your child until a preferred classroom option becomes available?
- Yes
- No
Child's Information (2nd child)
Program applying for:
- Head Start
- Early Head Start
- CCP
- New Participant
- Transition
- 3rd Year
Child's First Name
Child's Middle Name
Child's Last Name
Child's Gender
- Male
- Female
Child's Date of Birth
Race
Select more than one if necessary
If Other, please specify
Is English the child's primary language?
- Yes
- No
If yes, what is the child's English level?
- None
- Little
- Moderate
- Proficient
What is the child's primary language if English is not?
Level of child's primary language?
- Little
- Moderate
- Proficient
Is this child related to a HS / EHS employee?
- Yes
- No
If yes, name and relationship to the child
Is this child currently participating in the following?
- Pre-K Counts
- IU / Child Alert / Early Intervention
- N / A
- Unsure
Elementary School & district name which the family lives:
Have you applied with HS / EHS before for this child?
- Yes
- No
If yes, what year?
Is there a custody agreement regarding this child?
- Yes
- No
If yes, please provide / upload here
Max. file size: 50 MB.
Please provide / upload any Immunization records here
Max. file size: 50 MB.
Choose any of the following concerns the parent / guardian may have with the child
Any other concerns? ANY diagnostic documentation (IEP, IFSP, MH Evaluations) for any of the above concerns please list:
Please upload a copy of any diagnostic documentation (IEP, IFSP, MH Evaluation, etc.) if provided
Max. file size: 50 MB.
Head Start only: If the child's application is determined to be eligible for Pre-K Counts, I give permission for this information (contact, income, birth) to be shared with PIC Pre-K Counts Project Supervisor?
- Yes
- No
Head Start Only: Would you be interested in home-based service for your child until a preferred classroom option becomes available?
- Yes
- No
Child's Information (3rd child)
Program applying for:
- Head Start
- Early Head Start
- CCP
- New Participant
- Transition
- 3rd Year
Child's First Name
Child's Middle Name
Child's Last Name
Child's Gender
- Male
- Female
Child's Date of Birth
Race
Select more than one if necessary
If Other, please specify
Is English the child's primary language?
- Yes
- No
If yes, what is the child's English level?
- None
- Little
- Moderate
- Proficient
What is the child's primary language if English is not?
Level of child's primary language?
- Little
- Moderate
- Proficient
Is this child related to a HS / EHS employee?
- Yes
- No
If yes, name and relationship to the child
Is this child currently participating in the following?
- Pre-K Counts
- IU / Child Alert / Early Intervention
- N / A
- Unsure
Elementary School & district name which the family lives:
Have you applied with HS / EHS before for this child?
- Yes
- No
If yes, what year?
Is there a custody agreement regarding this child?
- Yes
- No
If yes, please provide / upload here
Max. file size: 50 MB.
Please provide / upload any Immunization records here
Max. file size: 50 MB.
Choose any of the following concerns the parent / guardian may have with the child
Any other concerns? ANY diagnostic documentation (IEP, IFSP, MH Evaluations) for any of the above concerns please list:
Please upload a copy of any diagnostic documentation (IEP, IFSP, MH Evaluation, etc.) if provided
Max. file size: 50 MB.
Head Start only: If the child's application is determined to be eligible for Pre-K Counts, I give permission for this information (contact, income, birth) to be shared with PIC Pre-K Counts Project Supervisor?
- Yes
- No
Head Start Only: Would you be interested in home-based service for your child until a preferred classroom option becomes available?
- Yes
- No
Primary Adult Information
Primary Parent First Name*
Primary Parent Middle Name
Primary Parent Last Name*
Date of Birth*
Gender
- Male
- Female
Email Address (account used most often)
Is English your primary language?
- Yes
- No
If yes, what is your English level?
- None
- Little
- Moderate
- Proficient
What is your primary language if English is not?
What is your level of primary language?
- Little
- Moderate
- Proficient
Relationship to child?*
- Foster
- Natural / Adopted?
- Grandparent
- Aunt / Uncle?
Do you provide financial support? (Please attach documentation below if so)
- Provides Financial Support
Race*
Select more than one if necessary
If Other, please specify
Employment Status*
- Full Time
- Part Time
- Retired or Disabled
- Training or School
- Full Time & Training
- Part Time & Training
- Seasonally Employed
- Self-Employed
- Unemployed
MUST select 1
Highest Grade Completed*
- Associate's Degree
- Attending School
- Bachelor's Degree
- Adult College or Advance Training
- Adult College Degree/Training Certificate
- Adult/Grade 9 or less
- Adult Grade 10
- Adult Grade 11
- Adult Grade 12 (did not graduate)
- General Ed. Diploma (GED)
- High School Graduate
- Master's Degree
MUST select 1
Secondary Adult Information **Required**
Is there secondary adult information?*
- Yes
- No, not applicable
Secondary Adult First Name
Secondary Adult Middle Name
Secondary Adult Last Name
Date of Birth
Gender
- Male
- Female
Email Address (account used most often)
Is English your primary language?
- Yes
- No
If yes, what is your English level?
- None
- Little
- Moderate
- Proficient
What is your primary language if English is not?
What is your level of primary language?
- Little
- Moderate
- Proficient
Relationship to child?
- Foster
- Natural / Adopted?
- Grandparent
- Aunt / Uncle?
Do you provide financial support? (Please attach documentation below if so)
- Provides Financial Support
Check if living with this family
- Lives with Family
Race
Select more than one if necessary
If Other, please specify
Employment Status
- Full Time
- Part Time
- Retired or Disabled
- Training or School
- Full Time & Training
- Part Time & Training
- Seasonally Employed
- Self-Employed
- Unemployed
MUST select 1
Highest Grade Completed
- Associate's Degree
- Attending School
- Bachelor's Degree
- Adult College or Advance Training
- Adult College Degree/Training Certificate
- Adult/Grade 9 or less
- Adult Grade 10
- Adult Grade 11
- Adult Grade 12 (did not graduate)
- General Ed. Diploma (GED)
- High School Graduate
- Master's Degree
MUST select 1
Family Contact Information
Primary Adult Living Address*
Street Address Address Line 2 City State ZIP Code
Primary Adult Mailing Address (if different)
Street Address Address Line 2 City State ZIP Code
Determination of Residency*
- Rent / Lease
- Live with family or others (If selected, a 'Residency Questionnaire' MUST be completed)
- Own
HEAD START ONLY: Is this child's physical address for classroom services the same as the primary adult's living address?
- Yes
- No
If no, what is the service address?
Secondary Adult Living Address (if not living with applicant)
Street Address Address Line 2 City State ZIP Code
Phone Numbers
Family Phone Number(s) Notes - Whose number is this (i.e. mom's cell, dad's work, etc.) Can we text this number? Is this the Primary Number?
Other Contacts (these are individuals not in Head Start Family)
Name (first & last) Relationship to child Phone Number(s)
Childcare Services
Have you been determined eligible and on a waitlist for ELRC subsidized funds?
- Yes
- No
Are you receiving Early Learning Resource Center (ELRC) subsidized funds?
- Yes
- No
Is your child receiving child care services (either in a daycare or a relative)?
- Yes
- No
If yes, what is the name of the child care facility or Person?
Phone Number of facility or person above?
County of facility or person above is located?
May Head Start, the Child Care listed above and ELRC share written information and have verbal communication regarding the Head Start/Early Head Start, Child Care and ELRC services?
- Yes
- No
Please list children that the above childcare questions applies to
Transportation
(Complete this section for HS children ONLY)
Are you able to transport to and from a Head Start center on a daily basis, if ‘yes’, your child may be placed on a priority list for a ‘parent transport only’ classroom:
- Yes
- No
If yes, please choose all Head Start Centers you will transport to and from daily below:
Transportation services are not guaranteed. Per the Transportation Policy, bus stop locations may be predetermined ‘centralized’ bus stops. NOTE: Due to a limited fleet of buses, it may be necessary for your family to meet the school bus for your child to be in a classroom.
If transportation is not available to your home or in walking distance from your home, are you able to transport to a central stop (up to 5 miles) 5 days/week:
- Yes
- No
I understand if I checked ‘No’ above, that I cannot meet the school bus, that other, more suitable placement for my child will be offered.
- Yes, I understand
Risk Assessment
Risk assessment to identify a child's need for services. Any out of the ordinary situations, see ERSEA Supervisor
Please choose all that apply
Child's name for what is selected above:
Please choose all that apply
Child's name for what is selected above:
Please choose all that apply
Child's name for what is selected above:
CYS Documentation file upload
Max. file size: 50 MB.
Family Income Information Used to Determine Eligibility
Income/Eligibility Information for Relevant Time Period (1) The 12 months preceding the month in which the application is submitted; or (2) During the calendar year preceding the calendar year in which the application is submitted, whichever more accurately reflects the needs of the family at the time of application.): Reminder: For each income source discussed, you MUST indicate month/year they started receiving the income and when it ended. If they are still receiving the income, put the month/year it began to present. Example: Sally began working at Walmart in January 2016 – March 2018. She then started working at Costco from April 2018-present. NOTE: if they are not reporting income for the entire Relevant Time Period, then ask if they worked prior and indicate in the notes below. Questions to keep in mind: Where did you work? How long did you work there? If not for a year, where before? How often were you paid?
Income Notes (if per diem, shift pay, overtime, how long at job, must gather more information):*
Certification*
I certify that all this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours. This information is confidential and will be handled accordingly; however If Head Start receives information that a client may have committed fraud or otherwise violated any criminal or civil statute or regulation, I AGREE THAT the program may relay those facts to the appropriate agency.
- I agree to the above Certification Statement
Internal Family Income Checklist – NOT USED TO DETERMINE ELIGIBILITY
Check the documentation collected & attached:
Please upload all income and birth verification documents here
Drop files here or

Max. file size: 50 MB.
- Income Tax Form 1040
- W-2
- Pay Stub or Pay Envelopes
- Bank Statements
- Unemployment
- Social Security Benefit (other than SSI):
- Survivor Benefit
- Disability
- Residency Questionnaire
- Self-Declaration of Income Worksheet
- Written Statements from employers
- Foster care reimbursement
- TANF documentation
- SSI documentation
- SNAP documentation
- Child Support Letter
Any Other documentation? Please Explain:
- Verification of No Income Form
- Verification of Birth
NOTES TO ERSEA

STAFF ONLY Head Start/Early Head Start of Fayette County - Application (1)

Overview Family Information

Child's Information (1st child)

Child's Information (2nd child)

Child's Information (3rd child)

Primary Adult Information

Secondary Adult Information Required

Family Contact Information

Childcare Services

Transportation

Risk Assessment

Family Income Information Used to Determine Eligibility

Internal Family Income Checklist – NOT USED TO DETERMINE ELIGIBILITY

Contact PIC

Join the PIC Team

Disclaimer

Additional Info

Search This Site

Adult or Child?	Last	First	DOB	Gender	Relationship to Applicant	Comments

Family Phone Number(s)	Notes - Whose number is this (i.e. mom's cell, dad's work, etc.) Can we text this number?	Is this the Primary Number?

Name (first & last)	Relationship to child	Phone Number(s)

STAFF ONLY Head Start/Early Head Start of Fayette County - Application (1)

Overview Family Information

Child's Information (1st child)

Child's Information (2nd child)

Child's Information (3rd child)

Primary Adult Information

Secondary Adult Information **Required**

Family Contact Information

Childcare Services

Transportation

Risk Assessment

Family Income Information Used to Determine Eligibility

Internal Family Income Checklist – NOT USED TO DETERMINE ELIGIBILITY

Contact PIC

Join the PIC Team

Disclaimer

Additional Info

Search This Site

Secondary Adult Information Required