Student Enrollment Form

Early Childhood Programs Application

Early Head Start / Pregnant Women & Children ages 0-3 and 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.
Child/Applicant Name *

First Name Middle Name Last Name
If you are a PREGNANT MOM applying for services for yourself, please put "Baby" as the "Child/Applicant Name" above, and the baby's due date as the "birthdate" below.
Birthdate *

Month Day Year
Date
Gender *
Social Security Number
Child's Race *

White Black/African American Biracial/Multiracial Other
Child's Ethnicity *

Hispanic or Latino Non-Hispanic or Latino
Program Applying For *

Early Head Start / Pregnant Women / Children birth - 3 years old Head Start / Children 3 - 5 years old
Center Preference (choose location for Head Start ONLY - if applying for Early Head Start, please select "Early Head Start" box as there is no center location for in-home Early Head Start services) *

Cresco Decorah Guttenberg Monona New Hampton Oelwein Postville Waukon Waverly West Union Early Head Start
Child's English-speaking Proficiency *

Proficient Moderate Little None
Does the child applicant speak another language? *

Yes No
If "YES" above, please specify which language
Child's Other Language Proficiency

Proficient Moderate Little
Is child acquiring/learning another language in addition to English? *

Yes No

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 Name Middle Name Last Name
Gender *
Birthdate *

Month Day Year
Date
Social Security Number
Adult Relationship to Child Applicant *

Biological Parent Adopted Parent Step-parent Foster Parent Grandparent Other
Primary Adult Race *

White Black/African American Biracial/Multiracial Other
Primary Adult Ethnicity *

Hispanic or Latino Non-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?

Yes No
Work Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Adult English-speaking Proficiency *

Proficient Moderate Little None
Does Primary Adult speak a language other than English? *

Yes No
If "YES" above, please specify which language
Primary Language Spoken at Home *

English Spanish Somali Other
Primary Adult Highest Grade Level Completed *

Grade 9 or less Grade 10 Grade 11 High School Graduate GED Some College or Training Associate Degree Bachelor Degree
Primary Adult Current Employment Status *

Full Time (35+ hours/week) Full Time and School Part Time (less than 35 hours/week) Part Time and School School Only Unemployed Disabled Retired
Does Primary Adult currently have custody of the Child Applicant?

Yes No
Does Primary Adult currently live in the SAME household as Child Applicant?

Yes No
Secondary Adult information (if there is not a Secondary Adult living in the household, please type "None" in the First Name box below - then skip down to address section)

First Name Middle Name Last Name
Secondary Adult Relationship to Child Applicant

Biological Parent Adopted Parent Step-parent Foster Parent Grandparent Other
Does Secondary Adult currently live in the SAME household as child applicant?

Yes No
Does Secondary Adult currently have custody of the Child Applicant?

Yes No
Gender
Birthdate

Month Day Year
Date
Secondary Adult Race

White Black/African American Biracial/Multiracial Other
Secondary Adult Ethnicity

Hispanic or Latino Non-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?

Yes No
Work Phone Number
Please enter a valid phone number.
Secondary Adult Highest Grade Level Completed

Grade 9 or less Grade 10 Grade 11 High School Graduate GED Some College or Training Associate Degree Bachelor Degree
Secondary Adult Current Employment Status

Full Time (35+ hours/week) Full Time and School Part Time (less than 35 hours/week) Part Time and School School Only Unemployed Disabled Retired
Family Living Address *

Street Address

Street Address Line 2

City State

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

Street Address

Street Address Line 2

City State / Province

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

Yes No
Is at least ONE parent/guardian an active member of the United States Military? *

Yes No
Is at least ONE parent/guardian a Military Veteran? *

Yes No
Were you referred by a Child Welfare Agency? *

Yes No
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.