CMEOC HS RETURNING APPLICATION

CHESTERFIELD-MARLBORO E.O.C. HEAD START

SCHOOL YEAR BEGINNING

SCHOOL YEAR END

Child Last Name

Child First Name

Child's Social Security Number

Child Birth Date

Date

Race

Black White Hispanic Native American Asian/Pacific Bi-Racial

Primary Adult

Parental Status

Single Married Foster Non-Parent Other

Primary Adult Social Security

Number in Family

Number of Children

0-3

4-5

Mailing Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Do you currently receive any of the following?

TANF WIC Medicaid (Place # below).

Do you receive any of the following?

Food Stamps Mental Health Services Other

Emergency Contact #1

Name

Street Address

City Zip Code

Phone

Emergency Contact #2

Name

Street Address

City Zip Code

Phone

Emergency Contact #3

Name

Street Address

City Zip Code

Phone

PERSONS AUTHORIZED TO PICK UP THE CHILD:

Authorized Person #1

Relationship

Phone

Authorized Person #2

Relationship

Phone

Authorized Person #3

Relationship

Phone

NEW HOUSEHOLD MEMBERS:

New Household Member #1

D.O.B

Date

Social Security

Education

Relationship to HOH

New Household Member #2

D.O.B.

Date

Social Security

Education

Relationship to HOH

HAVE THERE BEEN ANY CHANGES IN THE FOLLOWING:

Employment Status

If so, please elaborate

Education Status

If so, please elaborate

Other

If so, please explain

I CERTIFY THAT THIS INFORMATION IS TRUE. IF ANY PART IS FALSE, MY PARTICIPATION IN THIS AGENCY'S PROGRAM MAY BE TERMINATED AND I MAY BE SUBJECT TO LEGAL ACTION. I ALSO UNDERSTAND THAT THE INFORMATION GIVEN WILL BE HELD IN STRICT CONFIDENCE WITHIN THE AGENCY AND IS ACCESSIBLE TO ME DURING NORMAL BUSINESS HOURS.

Parent/Guardian

By typing my name above, i understand and agree that this form of electronic signature has the same legal force as a manual signature.

Date

CHESTERFIELD-MARLBORO EOC

Hospitalizations and Illnesses

Health Problems