Pregnant Mom Application for 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); The pregnant mother's most recent physical (can be filled out by your primary care provider or OB/GYN); and Copy of the pregnant mother's photo ID. 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. You 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 your enrollment.
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Pregnant Mother's Information
Pregnant Mother's Full Name
*
First Name
Last Name
Pregnant Mother's Birthdate
*
-
Month
-
Day
Year
Date
Pregnant Mother's 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
Pregnant Mother's Gender
*
Pregnant Mother's 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
Number of Weeks Pregnant
*
Due Date
-
Month
-
Day
Year
Mutiple Birth
*
Yes
No
Is the pregnancy considered high risk?
*
Yes
No
If yes, please describe
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
Pregnant Mother's Marital Status
*
Married
Single
Divorced
Widowed
Separated (Formally/Legally)
Separated (Informally)
Does the household receive food stamps?
*
Yes
No
If yes, DHHS Case Number
Does the household receive WIC?
*
Yes
No
Does anyone in the household receive SSI?
*
Yes, the pregnant mother
Yes, a minor child
Yes, another adult in the household
No
Is the pregnant mother a veteran or currently on active duty with the United States Military?
*
Veteran
Active Duty
No
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Other Parent's Information
Please include information if known
Other Parent's Full Name
First Name
Last Name
Other Parent's Birthdate
-
Month
-
Day
Year
Date
Other Parent's 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
Other Parent's Gender
Other Parent's Highest Level of Education
Please Select
Grade 9 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
Does the other parent live in the same household as the pregnant mother?
*
Yes
No
Is the other parent currently incarcerated?
*
Yes
No
Unknown
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Family Members In Household
Please list all other family members living in household
Family Member 1 Full Name
First Name
Last Name
Family Member 1 Birthdate
-
Month
-
Day
Year
Date
Family Member 2 Full Name
First Name
Last Name
Family Member 2 Birthdate
-
Month
-
Day
Year
Date
Family Member 3 Full Name
First Name
Last Name
Family Member 3 Birthdate
-
Month
-
Day
Year
Date
Family Member 4 Full Name
First Name
Last Name
Family Member 4 Birthdate
-
Month
-
Day
Year
Date
Family Member 5 Full Name
First Name
Last Name
Family Member 5 Birthdate
-
Month
-
Day
Year
Date
Family Member 6 Full Name
First Name
Last Name
Family Member 6 Birthdate
-
Month
-
Day
Year
Date
Are there any other additional family members in your household (not including the parent(s) of the unborn 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
-
Month
-
Day
Year
Date
Family Member 8 Full Name
First Name
Last Name
Family Member 8 Birthdate
-
Month
-
Day
Year
Date
Family Member 9 Full Name
First Name
Last Name
Family Member 9 Birthdate
-
Month
-
Day
Year
Date
Family Member 10 Full Name
First Name
Last Name
Family Member 10 Birthdate
-
Month
-
Day
Year
Date
Family Member 11 Full Name
First Name
Last Name
Family Member 11 Birthdate
-
Month
-
Day
Year
Date
Family Member 12 Full Name
First Name
Last Name
Family Member 12 Birthdate
-
Month
-
Day
Year
Date
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Medical/Miscellaneous
Pregnant Mother's OB/GYN
Pregnant Mother's OB/GYN Phone Number
Pregnant Mother's Dentist
Pregnant Mother's Dentist Phone Number
Pregnant Mother's Insurance Type
*
Please Select
Medicaid
Private Insurance
Tricare
None
Other
If Insurance other, please describe
Insurance ID or Policy Number
Does the pregnant mother have a disability?
*
Yes
No
If yes, please describe
Does the pregnant mother have any allergies?
*
Food
Insects
Seasonal Allergies
Other
None
If any allergies listed, please describe
Does the pregnant mother have asthma?
*
Yes
No
If yes, please list any medications used to control asthma
Are there any activities you do not wish to participate in for religious or personal reasons?
*
Yes
No
If yes, please describe
Do you need assistance in establishing paternity of your child and/or obtaining child support?
*
Yes
No
Do you need help getting or keeping track of Department of Health & Human Services benefits?
*
Yes
No
Have you drank the City of Flint water since you have been pregnant?
*
Yes
No
Which forms of income does your family have?
*
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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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 711 N. Saginaw St., Suite 1B, Flint, MI 48503.
By typing my initials in the box below I acknowledge that the pregnant mother's application will not be processed until I submit the following required documentation: income for all members of the household (most recent 1040 or W2s, most recent pay stubs, SSI letter, DHHS letter for cash assistance, etc), the pregnant mother's most recent physical, and a copy of the pregnant mother's photo ID.
*
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:
Pictures, photographs, or video tapes may be taken while participating in Early Head Start activities and I expressly waive the right of privacy and consent to such taking; I will participate in prenatal visits with my OB/GYN and provide necessary documentation to the Early Head Start program; in care of emergency, I give my consent to have Early Head Start staff secure needed emergency medical care, if I am unable to do this for myself; information in my personal file may be reviewed by government officials; I agree to participate as a volunteer in the Early Head Start program.
Electronic Signature (Please type full name)
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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