Child Application for Head Start / Early Head Start
Thank you for your interest in our free program. Please fill out the following application for our program. We use a secured platform to ensure any information provided and documents uploaded maintain the highest level of confidentiality.
You must also submit the following: Documentation of your family's income (most recent 1040 or W2s, most recent pay stubs, SSI letter, DHHS letter for cash or food assistance, etc); Your child's current physical; Your child's up to date immunization record or waiver from the Genesee Co Health Dept; Your child's Birth Certificate, Birth Record, or Affidavit of Parentage. You can attach these documents to this application electronically, fax them to 810-341-5852, or send through the United States Postal Service to GCCARD Head Start at 711 N. Saginaw Street, Suite 1B, Flint, MI 48503.
Please remember that our staff are not in the office every day, but will process the information you provide as quickly as we can. Your child will NOT be considered for placement into our program without the required documents listed above. Placement in our program is contingent on the availability of funding and is based on the Head Start regulations as well as our locally designed selection criteria. We look forward to working with you in regards to enrolling your child.
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Parent/Guardian Information
Parent/Guardian 1 Full Name
*
First Name
Last Name
Parent/Guardian 1 Birthdate
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Month
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Day
Year
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Parent/Guardian 1 Race/Ethnicity (Check all that apply)
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American Indian or Alaskan Native
Asian
Bi-racial or Multi-racial
Black or African American
Hispanic or Latino
Native American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
Parent/Guardian 1 Gender
*
Parent/Guardian 1 Highest Level of Education
*
Please Select
Grade 8 or less
Grade 10
Grade 11
Grade 12 (did not graduate)
High School Diploma
GED
Technical/Vocational Certificate
Some College (no degree)
Associates Degree
Bachelors Degree
Masters Degree or higher
What is the relationship of the Parent/Guardian 1 to the child?
*
Parent (biological/adoptive/step)
Grandparent
Family Member Other Than Grandparent
Foster Parent
Other
Does Parent/Guardian 1 live in the same household as the child?
*
Yes
No
Parent/Guardian 2 Full Name (if applicable)
First Name
Last Name
Parent/Guardian 2 Birthdate (if applicable)
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Month
-
Day
Year
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Parent/Guardian 2 Race/Ethnicity (Check all that apply) (if applicable)
American Indian or Alaskan Native
Asian
Bi-racial or Multi-racial
Black or African American
Hispanic or Latino
Native American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
Parent/Guardian 2 Gender
Parent/Guardian 2 Highest Level of Education (if applicable)
Please Select
Grade 8 or less
Grade 10
Grade 11
Grade 12 (did not graduate)
High School Diploma
GED
Technical/Vocational Certificate
Some College (no degree)
Associates Degree
Bachelors Degree
Masters Degree or higher
What is the relationship of the Parent/Guardian 2 to the child?
Parent (biological/adoptive/step)
Grandparent
Family Member Other Than Grandparent
Foster Parent
Other
Does Parent/Guardian 2 live in the same household as the child?
Yes
No
Phone Number
*
Street Address
*
City
*
Zip Code
*
E-Mail Address
Primary Language Spoken in Home
*
Please Select
African Languages
Arabic
Asian Languages
Caribbean
Dutch
English
Far Eastern Asian Languages
Italian
Korean
Middle Eastern
Native American Languages
Pacific Island Languages
Sign Language
Spanish
Turkish
Vietnamese
Other
If Language other, please describe
School District
*
Please Select
Atherton
Beecher
Bendle
Bentley
Carman-Ainsworth
Clio
Davison
Fenton
Flint
Flushing
Genesee
Goodrich
Grand Blanc
Kearsley
Lake Fenton
Lakeville
Linden
Montrose
Mount Morris
Swartz Creek
Westwood Heights
Other
If School District other, please describe
What is the marital status of the child's primary caregiver(s)?
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Married
Single
Divorced
Widowed
Separated (Formally/Legally)
Separated (Informally)
Does the household receive food stamps?
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Yes
No
If yes, DHHS Case Number
Does the household receive WIC?
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Yes
No
Does anyone in the household receive SSI?
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Yes
No
Is either parent/guardian currently pregnant?
*
Yes
No
Is either parent/guardian a veteran or currently on active duty with the United States Military?
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Veteran
Active Duty
None
Is either parent/guardian currently incarcerated?
*
Yes
No
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Child's Information
Please fill this section out for the child you are applying for (if you are applying for more than one child you will need to fill out a separate application for each of them)
Child's Full Name
*
First Name
Last Name
Birth date
*
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Month
-
Day
Year
Date Picker Icon
I certify this is the child's legal date of birth
*
Yes
No
Race/Ethnicity (Check all that apply)
*
American Indian or Alaskan Native
Asian
Bi-racial or Multi-racial
Black or African American
Hispanic or Latino
Native American
Native Hawaiian or Other Pacific Islander
White or Caucasian
Other
If Race/Ethnicity other, please describe
Gender
*
Does the child have a disability?
*
Yes
No
If yes, please specify
Is the child currently a foster child?
*
Yes
No
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Family Members In Household
Please list all other family members living in the household
Family Member 1 Full Name
First Name
Last Name
Family Member 1 Birthdate
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Month
-
Day
Year
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Family Member 2 Full Name
First Name
Last Name
Family Member 2 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 3 Full Name
First Name
Last Name
Family Member 3 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 4 Full Name
First Name
Last Name
Family Member 4 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 5 Full Name
First Name
Last Name
Family Member 5 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 6 Full Name
First Name
Last Name
Family Member 6 Birthdate
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Month
-
Day
Year
Date Picker Icon
Are there any additional family members in your household (not including the applying child)?
*
Yes
No
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Additional Family Members in Household
Please list any additional family members living in the household you did include on the previous page
Family Member 7 Full Name
First Name
Last Name
Family Member 7 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 8 Full Name
First Name
Last Name
Family Member 8 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 9 Full Name
First Name
Last Name
Family Member 9 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 10 Full Name
First Name
Last Name
Family Member 10 Birthdate
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Month
-
Day
Year
Date Picker Icon
Family Member 11 Full Name
First Name
Last Name
Family Member 11 Birthdate
-
Month
-
Day
Year
Date Picker Icon
Family Member 12 Full Name
First Name
Last Name
Family Member 12 Birthdate
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Month
-
Day
Year
Date Picker Icon
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Medical/Miscellaneous
Child's Primary Doctor
*
Child's Primary Doctor Phone Number
*
Child's Dentist
Child's Dentist Phone Number
Child's Insurance Type
*
Please Select
Medicaid
Private Insurance
Tricare
None
Other
If Insurance other, please describe
Insurance ID or Policy Number
Does your child have any allergies? (Check all that apply)
*
Food
Insects
Seasonal Allergies
Other
None
If any allergies listed, please describe
Does your child have asthma/asthma symptoms?
*
Yes
No
Is there any daily medications your child takes?
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Yes
No
If yes, please list daily medications
Is there any rescue medications your child has prescribed to them?
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Yes
No
If yes, please list rescue medications
Are there any activities you do not wish to have your child participate in for personal or religious reasons?
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Yes
No
If yes, please describe activities
Do you need assistance in establishing the paternity of your child and/or obtaining child support?
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Yes
No
Do you need help in getting or keeping track of Department of Health & Human Services benefits?
*
Yes
No
Were you pregnant with the child any time between April 2014 to present?
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Yes
No
If yes, did you drink the City of Flint water?
*
Yes
No
Does not apply
Did your child drink City of Flint water any time between April 2014 to present?
*
Yes
No
Which forms of income does the family have?
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Earned Income
Child Support
Unemployment Compensation
DHS Cash Assistance
Scholarships/Grants
Supplemental Security (SSI)
Social Security (SSA/SSDI)
Foster Child Stipend
Alimony
Business Income
Military/Veteran Income
Pension/Retirement
Rental Income
Farm Self Employment
Strike Benefits from Union Funds
Royalties from Estates or Trusts
Training Stipend
Regular Insurance or Annuity payments
Fellowship/Assistantship
Dividends
Gambling/Lottery Winnings
None
If our staff cannot reach you with the information you've provided please name a secondary contact person
*
First Name
Last Name
Phone number of contact person
*
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Program Needs
Which programming would you be interested in your child participating in? (Choose all that apply)
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Center based
Home based
If you selected center based, please check all that describe your need for full day services
Child has special education needs
Mother/guardian works outside the home
Father/guardian works outside the home
Mother/guardian is enrolled in educational program
Father/guardian is enrolled in educational program
Mother/guardian is disabled
Father/guardian is disabled
Other
If there is any other reason you have a need for full day services, please describe
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Additional Documentation
All additional documents described below can be submitted by attaching them to this application electronically, by fax to 810-341-5852, or by U.S. mail to GCCARD Head Start 601 N. Saginaw St., Suite 1B, Flint, MI 48502.
By typing my initials in the box below I acknowledge that my child's application will not be processed until I submit the following required documentation: income for all members of the household (2020 1040 or W2s, most recent pay stubs, SSI letter, DHHS letter for cash assistance, etc), my child's current physical, and my child's current immunization record or waiver from the Genesee County Health Department.
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Additional Documentation
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Parental Permission
I understand that by applying to Early Head Start/Head Start for my child I agree to the following:
Center Base: My child will attend class regularly and I will notify the center of the reason for any absences; two Home Visits and two Parent/Teacher Conferences will be scheduled during the program year at my convenience.
Home Base: I agree to participate in weekly home visits and attend socialization experiences twice per month.
General: Pictures, photographs, or video tapes of my child may be taken while participating in Head Start activities and I expressly waive the right of privacy and consent to such taking; my child may participate in all health activities including: dental, visual, hearing, mental health observations and consultations, and developmental screenings/examinations given as a part of the Head Start program (at no cost to me); in care of emergency, I give my consent to have Head Start staff secure needed emergency medical care, if parents or guardians cannot be immediately contacted; information in my child's personal file may be reviewed by government officials; necessary records may be released/transferred to the school system, GSRP, or other Head Start program that my child will attend after leaving the Head Start program; I agree to participate as a volunteer in the Head Start program.
If GCCARD Head Start is unable to serve your family do we have your permission to provide your name, contact information, and any enrollment documentation such as application, birth verification, income, physical, dental, immunization records to another local free preschool program that might be able to serve your family?
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Yes
No
Electronic Signature (Please type full name)
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First Name
Last Name
Today's Date
*
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Month
-
Day
Year
Date Picker Icon
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Application Complete
Thank you for applying for GCCARD Head Start/Early Head Start. In order to process your application we also need proof of all household income. If you have not attached them to this application already, please submit them via fax (810-341-5852) or through the United States Postal Service to GCCARD Head Start at 711 N. Saginaw Street, Suite 1B, Flint, MI 48502. While we also require documentation for birth verification, child's current physical, and immunization records we understand those may be difficult to obtain at this time. If you have them available please submit them along with your income documentation, or they can be collected at a later time.
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