2022-2023 Head Start Application

2022-2023 Head Start Application
Welcome!

Please complete one application per child and attach the required documents at the end of this application form.

Please note: This application is for the 2022-2023 school year to begin in the Fall of 2022. If you are looking to apply for the CURRENT school year, you can find the 2021-22 application on the Edwin Pratt ELC homepage.

Eligibility to our programs is determined by child’s age and family income, not by the date you applied. The information on your application is confidential and used only to determine your child’s eligibility for our Early Learning Programs. We do not require, check, or report on immigration or DSHS status.

Please allow yourself plenty of time to complete the application. You will be asked to upload the following required documents at the end. Please have them ready.

If you have any difficulties locating or obtaining any of the requested documents, please call our main office and ask to speak with a family advocate at (206) 393-4350. You can still complete and submit the application, however your child's application will be considered for enrollment only after all documents are received and approved.

Required Documents:

Proof of Income - use all that apply:
- 2021 Tax Return
- 2021 W-2 form
- Paystubs for the last 12 months
- SSI/TANF benefits letters for the last 12 months
- Foster Care Grant
- Child Support
- Employer letter stating total gross income from last 12 months
Proof of Family Size - us one of these:
- 2021 Tax Return that lists all members of the family
- Lease or Rental Agreement that list all members of the family
- Recent TANF/SSI/EBT benefit letters that list all members of the family
Proof of Child’s Age - use one of these:
- Birth Certificate
- Passport/Visa
- Adoption Papers
- Foster Care Authorization Letter
- Current Immunization Record
- DOC Residential Parenting Roster
Proof of Legal Guardianship - use one of these:
- Birth Certificate
- Passport/Visa
- Adoption Papers
- Foster Care Record
- Written agreement signed and dated by parent and person assuming custodial responsibility
Proof of Residency - use one of these:
- Property Tax bill
- Current Mortgage Statement
- Unexpired Lease Agreement
- Utility Bill dated within the last 3 months (water, sewer, gas, electric, or garbage)
Child Information - General
Child's Full Name *

Preferred Name Middle Initial Last Name
Gender *

Male Female
Date of Birth (month/day/year) *

Month Day Year
Date
What is this child's home language? *
Child's 2nd language: *
This child speaks *

Only English Mostly English and another language Some English, but mostly another language Both English and another language the same (bilingual) Only a language other than English
Is this child Hispanic/Latino? *

Yes No
What is this child's race? Check all that apply. *

African/African American/Black Native Hawaiian or Pacific Islander Asian White Alaska Native/Native American/American Indian Not listed above:
What is your family's heritage/tribe/country of origin? *
Is this child part of a tribe either by membership or by ancestry/lineage? *

Yes No
Has this child been previously enrolled in these programs? Only check the most recent. *

None Head Start/Early Head Start/ECEAP/Early ECEAP in King or Pierce County, Washington State Migrant/Seasonal Head Start Early Support for Infants and Toddlers (ESIT),ECLIPSE or any Birth-to-Three/Home Visiting Program Head Start/Early Head Start/ECEAP/Early ECEAP in another Washington State County
When did this child last attend?
Name and Location of program:
Is this child currently enrolled in a community slot at this site? *

Yes No
Is this child a sibling of a child currently enrolled in the program you are applying to? *

Yes No
The questions below are for information only. Answering "Yes" will not affect your eligibility or enrollment in the program.
Is this child in official foster care or kinship care with a grant amount? *

Yes No
If yes, what is the Case Number or Client ID Number?
What is the monthly grant/payment amount?
What is the monthly grant/payment source?

DSHS SSI Tribe Other
# of children covered by grant amount:
Is this child in kinship care without a grant amount? *

Yes No
Was this child adopted after foster care or kinship care or from an orphanage from another country? *

Yes No
Was this child recently reunited with their parent(s) after foster care or kinship care? *

Yes No
Does your family currently receive services /support through Child Protective Services (CPS), Family Assessment Response (FAR), Indian Child Welfare (ICW), comparable tribal services, or law enforcement/court system? *

Yes No
Has your family received services/support from CPS/FAR/ICW, comparable tribal services, or law enforcement/court system in the past? *

Yes No
Is your family currently approved for childcare through CPS or FAR? *

Yes No
If you answered yes to the previous question, how many approved hours a week?
Has this child ever been asked to leave an early learning program because of behavior issues? *

Yes No
Child Information - Health
Does this child have medical Insurance? *

Yes No
If yes, what type?

Washington Apple Health/ProviderOne Private Insurance Tribal Military Medical Coverage
Does this child have a regular doctor or medical clinic? *

Yes No
If yes, name of clinic/provider:
Name of medical professional
Did this child have a well-child exam within the last 12 months? *

Yes No Date Unknown
If yes, date of last exam (month/day/year)
Does this child have dental insurance? *

Yes No
If yes, what type?

Washington Apple Health/ProviderOne Private Insurance Tribal ABCD Military Dental Coverage
Does this child have a regular dentist or dental clinic? *

Yes No
If yes, name of clinic/provider:
Name of dental professional
Did this child have dental exam within the last 6 months? *

Yes No Date Unknown
If yes, date of last exam (month/day/year)
What is your child's immunization status? *

Fully immunized Exempt Not fully immunized or exempt Not sure
Does this child have a chronic health condition (may include mental health, asthma, cancer, diabetes, seizures, ADHD, autism, spina bifida, sickle cell disease, or life-threatening allergies)? *

Yes No
If you answered YES, to the previous question please describe the health condition:
If your child does have a chronic health condition, is the health condition considered:

Severe Moderate Mild
Has a health care provider diagnosed this condition

Yes No
Child Information - Development
Do you have concerns about this child's health? *

Yes No
If you answered yes, to the previous question please check all that apply

Low birth weight less than 5.5 lbs/5 lbs 8 oz Preterm birth less than 37 weeks Drug/alcohol affected Hearing Fine motor/gross motor Tooth pain/decay/bleeding gums Vision Food intolerance/special diet
If you checked Food intolerance/special diet, please describe
Does this child have a current and active Individual Education Plan (IEP) or Individual Family Service Plan (IFSP)? *

Yes - Please provide a copy with your application. No
If you checked No, to the previous question please check if any of these apply

My child has a diagnosed developmental delay or disability, has no IEP, or is being referred for evaluation. My child has a suspected developmental delay or disability.
Parent/Guardian Information
This child lives with *

One parent/guardian (complete Parent/Guardian 1) Two parents/guardians in the same household (complete Parent/Guardian 1 & 2) Two parents/guardians in two households (complete Parent/Guardian 1 & 2)
Parent/Guardian 1
Parent Guardian Name *

First Name Last Name
Relationship to Child *

Biological/Adopted/Stepparent Foster Parent Aunt/Uncle Grandparent Other:
Gender *

Male Female Not Specified
Date of Birth (month/day/year) *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *
Please enter a valid phone number.
Primary Phone: *

Home Cell Work
Alternate Phone Number
Please enter a valid phone number.
Alternate Phone:

Home Cell Work
Email *
example@example.com
Were you under age 18 when this child was born? *

Yes No N/A
What language(s) do you speak? *
Do you need an interpreter for this language? *

Yes No
What is your race? *

African/African American/Black Asian Alaska Native/Native American/American Indian Native Hawaiian or Pacific Islander White Not listed above
If you marked not listed above, please describe:
What is the highest level of education you completed? *

6th grade or less 7th to 12th grade, no diploma or GED High school diploma GED Some college/advanced training College/professional certificate Associate degree Bachelor's degree Master's or doctorate degree None
Are you currently employed? *

Yes No No, retired or disabled Seasonal
If you ARE employed how many hours per week (including travel)?
Employer Name
Employer Phone Number
Please enter a valid phone number.
Are you currently in job training or school? *

Yes No
If you ARE currently in job training or school, how many hours per week (including class time, study time, travel)
School name & Major/Goal
Are you in an approved WorkFirst activity? *

Yes No
If you are in an approved WorkFirst activity please describe the activity and the number of approved hours per week:
Are you or have you been in the U.S. military? *

Yes, current service member Yes, currently deployed or have been in the last 12 Yes, veteran No
Parent/Guardian 2
Parent Guardian Name

First Name Last Name
Relationship to Child

Biological/Adopted/Stepparent Foster Parent Aunt/Uncle Grandparent Other:
Gender

Male Female Not Specified
Date of Birth (month/day/year)

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Primary Phone:

Home Cell Work
Alternate Phone Number
Please enter a valid phone number.
Alternate Phone:

Home Cell Work
Email
example@example.com
Were you under age 18 when this child was born?

Yes No N/A
What language(s) do you speak?
Do you need an interpreter for this language?

Yes No
What is your race?

African/African American/Black Asian Alaska Native/Native American/American Indian Native Hawaiian or Pacific Islander White Not listed above
If you marked not listed above, please describe:
What is the highest level of education you completed?

6th grade or less 7th to 12th grade, no diploma or GED High school diploma GED Some college/advanced training College/professional certificate Associate degree Bachelor's degree Master's or doctorate degree None
Are you currently employed?

Yes No No, retired or disabled Seasonal
If you ARE employed how many hours per week (including travel)?
Employer Name
Employer Phone Number
Please enter a valid phone number.
Are you currently in job training or school?

Yes No
If you ARE currently in job training or school, how many hours per week (including class time, study time, travel)
School name & Major/Goal
Are you in an approved WorkFirst activity?

Yes No
If you are in an approved WorkFirst activity please describe the activity and the number of approved hours per week:
Are you or have you been in the U.S. military?

Yes, current service member Yes, currently deployed or have been in the last 12 Yes, veteran No
Family Concerns
Please check areas of concern that you have for yourself/family household.

Household member has a disability or has a chronic physical or mental health condition and is Child's parents/guardian has learning difficulties, no disability Household domestic violence (past or current), including in utero Household drug/alcohol issues or substance abuse (past or current), including in utero Family is socially isolated, with complete or near-complete lack of contact with others Child's parent/guardian concern for getting or keeping a job Family has legal concerns Child has a family member who attended Indian Boarding School Child's parent/guardian is a migrant or seasonal worker with more than half of family income coming from agricultural work Parent and child moved to engage in traditional cultural practices or employment (seasonal or temporary in agricultural or fishing) Recent immigrant/refugee (past 5 years) Child's parent/guardian is incarcerated Loss of a parent (death, abandonment, or deportation) Child's parents/guardians divorced or separated during child''s life Family previously homeless (in the last 12 months) Family concerns with housing
Child's parent/guardian has a disability or is chronically ill and is:

Unable to engage in work/school/family life Somewhat able to engage in work/school/family life Mostly able to engage in work/school/family life
Family Living Situation
Does this household receive subsidized housing such as a housing voucher or cash assistance for housing? *

Yes No
What is your family's current housing situation? The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. Your answers may help us determine the services your child may be eligible to receive. *

Own Rent In someone else's house or apartment with another family In a motel In a shelter A car, park, campsite, or similar location Transitional Housing Moving from place to place/couch surfing In a residence with inadequate facilities (no water, heat, electricity) Other, please describe:
If you are living in someone else's house or apartment with another family is it:

By choice (e.g. to share responsibilities, to be close to family, etc) Due to loss of housing, economic hardship, or similar reason
Family Income and Family Size
Check all that apply if you, this child, or another person living in your home related to you by blood, marriage, or adoption receive these types of Public Assistance.

SSI for disability Temporary Assistance for Needy Families (TANF)cash
Who is the SSI disability received by:

Child Parent/Guardian Other
Check all that apply if your family receives the following:

Child-only TANF WorkFirst Working Connections Child Care subsidy SNAP WIC
Were you referred to this program by an agency? *

Yes No
If you were referred by an agency, please list below:
Please list additional people living in this child's primary household below, NOT including yourself or this child.
1 - Name

First Name Last Name
1 - Birthday (month/day/year)

Month Day Year
Date
1 - Relationship to child
Do you financially support this person?

Yes No
Is this person related to you by blood, marriage, or adoption?

Yes No
Do you have additional people to add?

Yes No
2 - Name

First Name Last Name
2 - Birthday (month/day/year)

Month Day Year
Date
2 - Relationship to child
Do you financially support this person?

Yes No
Is this person related to you by blood, marriage, or adoption?

Yes No
Do you have additional people to add?

Yes No
3 - Name

First Name Last Name
3 - Birthday (month/day/year)

Month Day Year
Date
3 - Relationship to child
Do you financially support this person?

Yes No
Is this person related to you by blood, marriage, or adoption?

Yes No
Do you have additional people to add?

Yes No
4- Name

First Name Last Name
4 - Birthday (month/day/year)

Month Day Year
Date
4 - Relationship to child
Do you financially support this person?

Yes No
Is this person related to you by blood, marriage, or adoption?

Yes No
Do you have additional people to add?

Yes No
5 - Name

First Name Last Name
5 - Birthday (month/day/year)

Month Day Year
Date
5 - Relationship to child
Do you financially support this person?

Yes No
Is this person related to you by blood, marriage, or adoption?

Yes No
Do you have additional people to add?

Yes No
6 - Name

First Name Last Name
6 - Birthday (month/day/year)

Month Day Year
Date
6 - Relationship to child
Do you financially support this person?

Yes No
Is this person related to you by blood, marriage, or adoption?

Yes No
What is the total number of family members living in your home, including yourself and this child? *
What is your total estimated household income for the last calendar year or the last 12 months? *
Early Learning Application 2022-2023

I promise that the information on this form is true and correct. I have reported all my income and family size, as required by the Early Learning Programs. If I knowingly provide false information, I understand my family may be unable to continue program services. Additionally, if my child is enrolled in ECEAP, I may have to repay the amount spent on my child.

I understand that information from this application is entered in various Early Learning databases operated by the Department of Children, Youth, and Families (DCYF) and Puget Sound Educational Service District (PSESD DCYF and PSESD are committed to protecting confidential and personal information that could identify a child or family. No information related to immigration status is entered in the databases or shared with state or federal agencies. Information in the databases may be used for the following:
- Research studies to determine if participating in Early Learning helps children later in life.
- To prove Washington State spends some of their own dollars on programs for families, which is required to receive Temporary Assistance for Needy Families dollars from the federal government.
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Date

Early Learning Application 2022-2023

Document Upload
If you have any difficulties locating or obtaining any of the requested documents, please call our main office and ask to speak with a family advocate at (206) 393-4350. You can still complete and submit the application, however your child's application will be considered for enrollment only after all documents are received and approved.

Required Documents:

Proof of Income - use all that apply:
- 2021 Tax Return
- 2021 W-2 form
- Paystubs for the last 12 months
- SSI/TANF benefits letters for the last 12 months
- Foster Care Grant
- Child Support
- Employer letter stating total gross income from last 12 months
Proof of Family Size - us one of these:
- 2021 Tax Return that lists all members of the family
- Lease or Rental Agreement that list all members of the family
- Recent TANF/SSI/EBT benefit letters that list all members of the family
Proof of Child’s Age - use one of these:
- Birth Certificate
- Passport/Visa
- Adoption Papers
- Foster Care Authorization Letter
- Current Immunization Record
- DOC Residential Parenting Roster
Proof of Legal Guardianship - use one of these:
- Birth Certificate
- Passport/Visa
- Adoption Papers
- Foster Care Record
- Written agreement signed and dated by parent and person assuming custodial responsibility
Proof of Residency - use one of these:
- Property Tax bill
- Current Mortgage Statement
- Unexpired Lease Agreement
- Utility Bill dated within the last 3 months (water, sewer, gas, electric, or garbage)
File Upload *

Cancel of
Should be Empty:

2022-2023 Head Start Application

Child Information - General

Child Information - Health

Child Information - Development

Parent/Guardian Information

Family Concerns

Family Living Situation

Family Income and Family Size

Early Learning Application 2022-2023