* If a family has more than one child applying for services, please complete a separate copy of this form for each applicant.
In order for our staff to provide services that meet your child's individual needs, please answer the following:
Being "potty trained" is not a requirement of our program. This awareness just helps us in determining placement and in working with parents to meet the needs of the child.
Head Start values the involvement of both parents in their child's life. If parents of the child do not live together, please provide the following information for the non-custodial parent (not the primary caretaker of the child):
Parent/Guardian/Eligible Student (over 18, own guardian):
Your signature on this Authorization for Exchange of Information will give the individuals, programs, organizations, and entities listed on the following page(s) of this Authorization permission to exchange the information indicated below.
Before giving your permission for exchange of information, please carefully review the following:
This authorization is good until the following date, __________, or until one year after the date of signing, whichever occurs first. You may revoke this authorization, in writing, at any time, however, this does not affect information shared prior to your request for revocation. All members of the IEP team and, as appropriate, those identified as having legitimate educational interest may review the information received. The information may also be used in the future, including if the student moves, for the purpose of IEP decision making.
Health Insurance Portability and Accountability Act (HIPAA)/Family Educational Rights and Privacy Act (FERPA) Notice:
Any and all personally identifiable information regarding children receiving special education services funded under the Individuals with Disabilities Act (20 U.S.C. section 1400 et seq.) is protected from unauthorized disclosure under FERPA. Personally identifiable information protected by FERPA is specifically exempted from HIPPA privacy standards. FERPA prohibits disclosure of personally identifiable information without parent consent except in limited circumstances, requires notice to be provided to the child's family regarding their privacy rights, requires providers to keep records of access to a student's records, and contains complaint and appeal procedures which apply to disputes over records in possession of special education or its providers, among other provisions. All special education providers comply with these procedures.
If you have questions, please contact:
Prairie Lakes AEA1235 5th Ave. SouthFort Dodge, IA 50501515-574-5500
Name: Y.O.U.R., Inc. Head Start Zero-Five
Agency/Relationship: Y.O.U.R., Inc. Head Start Zero-Five
Address: 214 S. 13th Street
Fort Dodge, IA 50501
Name: Prairie Lakes AEA
Agency/Relationship: Prairie Lakes AEA
Address: 1235 5th Avenue South
I hereby authorize the sharing of confidential information, including immunization records, hemoglobin, leads, dentals and fluorides, pertaining to my child.
Public Health in Humboldt, Hamilton, Wright and/or Webster Counties
Y.O.U.R., Inc. Head Start Zero-Five
214 S.13th St.
Fort Dodge, IA 50501
I hereby authorize you to furnish to Your Own United Resources, Inc.Head Start Zero-Five confidential information pertaining to:
To: Informant Department of Human Services
Address 330 1st Ave. North
Fort Dodge, IA 50501
Phone (515) 573-1678 Fax (515) 955 6353
As a participant or parent/guardian/foster parent of a child participant in a program administered by Your Own United Resources, Inc., I understand that personal information for my household will be entered into one or more web based data collection programs. This information will be used to determine eligibility, facilitate enrollment in the program(s) and provide for ongoing documentation and monitoring of the services received.
Access to this information requires security codes for entry and other safeguards are in place to assure that this information remains confidential and is used only for the purpose of participation in a Your Own United Resources, Inc. program.
My signature below authorizes the staff of Your Own United Resources, Inc. to enter information into data collection programs as necessary for me or a member of my household to participate and receive services, through the Head Start and Early Head Start programs.
I understand that this authorization will remain in effect for the entire time that I am receiving services and the time frame necessary for closing and reporting data after I am, or my child is, no longer a participant in the program(s).
This authorization is good for one year from the above date.
COMPLETE ONE FORM FROM EACH PERSON EARNING INCOME:
1. DHS Current FIP Printout
2. Employer Wages
3. Child Support/Alimony
Y.O.U.R., Inc. HEAD START
214 South 13th St.
Fort Dodge, IA 50501
Because eligibility for Head Start and Early Head Start services is based on 100% of the Federal Poverty Guidelines, the family’s income must be verified by Your Own United Resources, Inc. staff before determining that a child or pregnant mom is eligible to participate in the program(s). Verification must include examination of any of the following: Individual Income Tax Form 1040, W-2 forms, pay stubs, written verifications from employers and/or documentation showing current status as recipients of public assistance.
If an applicant cannot furnish sufficient information to determine income eligibility with the above documents, it is necessary to complete this Minimum Income Statement.
Have you or any family member had income from any of these sources during the past twelve months?
Please describe how your household has met the following basic needs during the past twelve months:
Have the applicant sign an Income verification form for each source of income that is verifiable. The Income Verification form must include the name and address of the employer, agency, etc. that provided income. The form then needs to be mailed or faxed to the address indicated and returned to Your Own United Resources, Inc.
The Eligibility Priority Criteria is used by Y.O.U.R., Inc. Head Start Zero–Five to select children for the program based on information from your application.
The point system ensures that the most at-risk children are served by the program. Income, age, parental status and disability are four areas considered for acceptance. The other area considered involves social service issues, referrals, serious child health problems, substance abuse, domestic violence, English as a second language, etc. This criteria is based on information that relates only to your child’s immediate family; mother, father, brother, sister, or any other family member that lives in your home.
In order for us to complete the Eligibility Priority Criteria, we need your help. Although you may feel uncomfortable revealing personal family information, please be assured that all information on your application is strictly confidential and is used only for Head Start purposes.
Please mark yes or no to each situation. If yes, provide more information that applies to your child’s immediate family situation currently or in the past year so that we can accurately determine your priority points.