Student Enrollment Application Form

Early Childhood Programs Application

Early Head Start / Pregnant Women & Children ages 0-3 Head Start / Children ages 3-5
Important**

Please fill out ONE application PER PERSON. If you are applying for more than one child, you will need to fill out a separate application for each child. If you are a pregnant mother applying for services, and also have a child eligible for Early Head Start, you will need to do two separate applications.
Applying For*

Early Head Start - In Home Visits ONLYHead Start - CURRENT SCHOOL YEAR - 2024 / 2025
Center Preference

Early Head Start - If you are applying for Early Head Start, you do not need to select a center location as it is In-Home Visits ONLY.

Head Start - If you are applying for Head Start, please select a specific center location from the list below.
HEAD START ONLY - Center Location

CrescoDecorahGuttenbergMononaNew HamptonOelweinPostvilleWaukonWaverlyWest Union
If you are a PREGNANT MOM applying for services for yourself:

First Name = type in the name "Baby"

Last Name = type in your last name

Birthdate = baby's due date
Child/Applicant Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Date
Gender*
Social Security Number
Child's Race*

WhiteBlack/African AmericanBiracial/MultiracialOther
Child's Ethnicity*

Hispanic or LatinoNon-Hispanic or Latino
Child's English-speaking Proficiency*

ProficientModerateLittleNone
Does the child applicant speak another language?*

YesNo
If "YES" above, please specify which language
Child's Other Language Proficiency

ProficientModerateLittle
Is child acquiring/learning another language in addition to English?*

YesNo

Other Children Living in Household

	First Name	Last Name	Male / Female	Birthdate	Relationship to Child Applicant
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

Primary Adult information*

First NameMiddle NameLast Name
Gender*
Birthdate*

MonthDayYear
Date
Social Security Number
Adult Relationship to Child Applicant*

Biological ParentAdopted ParentStep-parentFoster ParentGrandparentOther
Primary Adult Race*

WhiteBlack/African AmericanBiracial/MultiracialOther
Primary Adult Ethnicity*

Hispanic or LatinoNon-Hispanic or Latino
Cell Phone Number*
Please enter a valid phone number.
Do you give permission to receive text messages on the above phone number?

YesNo
Work Phone Number (if applicable)
Please enter a valid phone number.
Land Line (HOME) Phone Number (if applicable)
Please enter a valid phone number.
Email
example@example.com
Primary Adult English-speaking Proficiency*

ProficientModerateLittleNone
Does Primary Adult speak a language other than English?*

YesNo
If "YES" above, please specify which language
Primary Language Spoken at Home*

EnglishSpanishSomaliOther
Primary Adult Highest Grade Level Completed*

Grade 9 or lessGrade 10Grade 11High School GraduateGEDSome College or TrainingAssociate DegreeBachelor Degree
Primary Adult Current Employment Status*

Full Time (35+ hours/week)Full Time and SchoolPart Time (less than 35 hours/week)Part Time and SchoolSchool OnlyUnemployedDisabledRetired
Does Primary Adult currently have custody of the Child Applicant?

YesNo
Does Primary Adult currently live in the SAME household as Child Applicant?

YesNo
Is there another Adult living in the same household?*

YesNo
Secondary Adult information *

First NameLast Name
Secondary Adult Relationship to Child Applicant

Biological ParentAdopted ParentStep-parentFoster ParentGrandparentOther
Does Secondary Adult currently live in the SAME household as child applicant?

YesNo
Does Secondary Adult currently have custody of the Child Applicant?

YesNo
Gender
Birthdate

MonthDayYear
Date
Secondary Adult Race

WhiteBlack/African AmericanBiracial/MultiracialOther
Secondary Adult Ethnicity

Hispanic or LatinoNon-Hispanic or Latino
Cell Phone Number
Please enter a valid phone number.
Do you give permission to receive text messages on the above phone number?

YesNo
Work Phone Number
Please enter a valid phone number.
Secondary Adult Highest Grade Level Completed

Grade 9 or lessGrade 10Grade 11High School GraduateGEDSome College or TrainingAssociate DegreeBachelor Degree
Secondary Adult Current Employment Status

Full Time (35+ hours/week)Full Time and SchoolPart Time (less than 35 hours/week)Part Time and SchoolSchool OnlyUnemployedDisabledRetired
Family Living Address*

Street Address

Street Address Line 2

CityState

Zip Code
Family Mailing Address - if DIFFERENT than Living Address above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you been Homeless in the past 12 months (including currently homeless)?*

YesNo
Is at least ONE parent/guardian an active member of the United States Military?*

YesNo
Is at least ONE parent/guardian a Military Veteran?*

YesNo
Were you referred by a Child Welfare Agency?*

YesNo
Thank you for filling out the Early Childhood Programs application. A Family Service Specialist will be contacting you to complete the application and eligibility process.
I, name* , certify the information provided in support of this application is accurate and truthful to the best of my knowledge.
Should be Empty:

Early Childhood Programs Application

Important**

Thank you for filling out the Early Childhood Programs application. A Family Service Specialist will be contacting you to complete the application and eligibility process.