Head Start and Child Care Pre-Application Form

Head Start and Child Care Pre-Application Form

1950 Redding Rancheria Rd, Redding, CA 96001 Phone: (530)225-8925 Fax: (530)2258930
Child:
Name*

First NameLast Name
Suffix
Nickname
Date of Birth*

MonthDayYear
Date
Gender*
SSN*
Alternate ID
Race*
Tribe Name
YesNo
English Proficiency*
Other Language
Other Language Proficiency
Has this child been diagnosed or suspected to have any special needs?*
Identify
Medicaid Eligibility*
Medicaid #
Doctor/Medical Home

Primary Adult:
Name*

First NameLast Name
Suffix
Nickname
Date of Birth*

MonthDayYear
Date
Gender*
SSN*
Alternate ID
Race*
Tribe Name
Other Race
YesNo
English Proficiency*
Other Language
Other Language Proficiency
Highest Grade Completed*
Employment Status*
Child's Relationship*
Custody*
Lives with FamilyProvides Financial SupportTeen Parent
If teen parent, subsidized?
Email*
example@example.com

Secondary or Other Adult:
Name

First NameLast Name
Suffix
Nickname
Date of Birth

MonthDayYear
Date
Gender
SSN
Alternate ID
Race
Tribe Name
Other Race
YesNo
English Proficiency
Other Language
Other Language Proficiency
Highest Grade Completed
Employment Status
Child's Relationship
Custody
Lives with FamilyProvides Financial SupportTeen Parent
If teen parent, subsidized?
Email
example@example.com

Additional Child/Sibling (Non-Applicant):
Name

First NameLast Name
Suffix
Nickname
Date of Birth

MonthDayYear
Date
Gender
SSN
Race
Tribe Name
Other Race
YesNo
English Proficiency
Other Language
Other Language Proficiency

Additional Child/Sibling (Non-Applicant):
Name

First NameLast Name
Suffix
Nickname
Date of Birth

MonthDayYear
Date
Gender
SSN
Race
Tribe Name
Other Race
YesNo
English Proficiency
Other Language
Other Language Proficiency
**If a family has more than one child applying for services, please complete a separate copy of this form for each applicant.

Family Information, Income & Contacts:
Family Living Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Started living at Date*
Family Mailing Address is same as living address*
Family Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Phone Type*
Extension or Best time to call*
YesNo
Additional Phone Number

Area CodePhone Number
Parental Status*
Primary Language at Home*
Relationship to Participant(s)*
Acquired/learning another language in addition to English*
Homeless Family*
Active Duty Military *
Military Veteran*
Referred by Child Welfare Agency*
Receiving SNAP*
WIC*

Family Income:

List all income in the household*

Rows	Family Member	Amount	Per(For example: Week, Month, Year)	Annual Amount	Description(For example: SSI, Job, Child Support)	Verification(For example: W2, Stub)	Note
1.
2.
3.
4.
5.

Certification: I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accesible to me during my normal business hours.
Parent/ Guardian Signature*

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty: