FACT, Inc Preschool Child Application

Families and Children Together, Inc

Early Head Start (EHS) | Head Start (HS) | Arkansas Better Chance (ABC) Child Application
If you have problems with submitting the form, please contact info@fact-inc.com
APPLICATIONS WILL NOT BE ACCEPTED WITHOUT COPIES OF THE FOLLOWING DOCUMENTATION

1. A form of legal documentation to prove the child’s age:
birth certificate, hospital record or Medicaid/AR Kids card

2. Household income verification for the past twelve months:
One month of check stubs, tax returns, W-2s, employer statements, TEA, SSI, Unemployment, SNAP, WIC, etc. Household income includes all means of support for the last twelve months from all parents/guardians of the child who also live in the same household as the child.

If the child has a diagnosed disability, documentation relating to the disability must be provided along with this application.

If your child is accepted for enrollment in one of our programs, then you will be asked to supply copies of the following documentation (you may also provide these documents now in order to expedite the enrollment process):

1. State birth certificate or hospital record
Applications for Arkansas state birth certificates are available from F.A.C.T., Inc. upon request.

2. Immunization Record
Shots must be current according to the age of the child. Check with your physician or local health clinic.

3. Medicaid Card/AR Kids or Private Insurance (if applicable).
Medicaid/AR Kids applications are available upon request.

Should you have any questions regarding the required information, please contact the ERSEA Coordinator at (870) 862-4545 or your local center.
Required Documentation

You can attach pictures of documents, screen caps, or saved files.
1. State Birth Certificate or Hospital Record*

THIS IS A REQUIRED ATTACHMENT. YOU CANNOT SUBMIT THE APPLICATION WITHOUT THE ATTACHMENT.
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2. Immunization Record*

THIS IS A REQUIRED ATTACHMENT. YOU CANNOT SUBMIT THE APPLICATION WITHOUT THE ATTACHMENT.
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3. Medicaid Card/AR Kids or Private Insurance (If applicable)

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4. ((If you do not have any income, upload a statement stating so and you will be contacted for other needed documents)) One month of check stubs, tax returns, W-2s, employer statements, TEA, SSI, Unemployment, SNAP, WIC, etc. Household income includes all means of support for the last twelve months from all parents/guardians of the child who also live in the same household as the child.

Allows multiple files to be attached
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Program you are applying for:

Center Based (Your child will come to our facility.)Home Based (Early Head Start Only. Our teacher will come to your home.)
Please indicate where you would like your child placed. Check all locations convenient to you.

Bearden HS/EHS/ABCBradley HSCamden HS/EHS/ABCEmerson HSFairview HS/EHS-EI DoradoFordyce HS/EHSHampton EHSHope HSJunction City HS/EHS/ABCMagnolia EHSMagnolia East HS/ABCMcNeil HSMorning Start HS/EHSNevada HS-RosstonStrong HS/EHS/ABCTaylor ABCWest Woods HS/EHS/ABC- El Dorado
Limited bus transportation is available for: Bradley Head Start. There is NO transportation available for Early Head Start (infant and toddler program)
Is anyone in your household expecting a baby?

NoYes If yes, please also completed an application for a Pregnant Mom application.
Applicant Information

The Child's Information
First Name
Middle Name
Last Name
Jr., II, III
Date of Birth

MonthDayYear
Date
Gender
Weight at Birth: POUNDS (lbs)
Weight at Birth: OUNCES (oz)
Race

AsianBlackWhiteAmerican Indian/Alaska NativeHawaiian/Pacific IslanderMulti Racial
Other Race:
Hispanic

YesNo
English Proficiency

NoneLittleModerateProficient
Other Language:
Other Language Proficiency

PoorModerateProficient
Primary Health Coverage

AR KidsMedicaidPrivateNone
Medicaid/Insurance #
Social Security Number
How did you hear about us?

agency employeechild previously enrolled referred by another agency E-mail address: Jr., Sr., Lastfamily/friendinternet/websiteNewspaperRadioReferred by Another AgencySibling AttendedWalk-InWord of Mouth
E mail address
example@example.com
The Primary Parent/Guardian Information
First Name
Middle Name
Last Name
Jr., Sr., II
Date of Birth

MonthDayYear
Date
Gender
Race

AsianAmerican Indian/Alaska NativeBlackHawaiian/Pacific IslanderWhiteMulti Racial
Other Race
Hispanic

YesNo
English Proficiency

NoneLittleModerateProficient
Other Language
Other Language Proficiency

PoorModerateProficient
Highest Grade Completed

Master'sBachelor'sAssociate'sSome CollegeTraining CertificateHigh School GraduateGEDGrade 11Grade 10Grade 9 or Less
Employment Status

Full TimePart TimeSeasonalUnemployedFull Time & SchoolPart Time & SchoolTraining or SchoolRetired or Disabled
Child's Relationship

Biological/Adopt/StepFosterGrandchildOther Relative
Do you have custody?

YesNo
Check all that apply:

Lives with familyProvides financial supportTeen Parent
Is parent attending school? WHERE
# of hours/semester
Secondary Parent/Guardian

Only complete this section if the secondary parent/guardian lives in the household
First Name
Middle Name
Last Name
Jr., Sr., II
Date of Birth

MonthDayYear
Date
Gender
Race

AsianBlackWhiteAmerican Indian/Alaska NativeHawaiian/Pacific IslandMulti-Racial
Other Race
Hispanic

YesNo
English Proficiency

NoneLittleModerateProficient
Other Language
Other Language Proficiency

PoorModerateProficient
Highest Grade Completed

Master'sBachelor'sAssociate'sSome CollegeTraining CertificateHigh School GraduateGEDGrade 11Grade 10Grade 9 or Less
Employment Status

Full TimePart TimeSeasonalUnemployedFull Time & SchoolPart Time & SchoolTraining or SchoolRetired or Disabled
Child's Relationship

Biological/Adopt/StepFosterGrandchildOther Relative
Custody

YesNo
Check all that apply

Lives with familyProvides Financial SupportTeen Parent
Is parent attending school? Where?
Number of hours per semester:
Additional People Living in the Home

Need a full name, date of birth, and relationship to child for each individual
Person 1

First NameLast Name
Person 1 Date of Birth

MonthDayYear
Date
Person 1 Relationship to Child
Person 2 Name

First NameLast Name
Person 2 Date of Birth

MonthDayYear
Date
Person 2 Relationship to Child
Person 3 Name

First NameLast Name
Person 3 Date of Birth

MonthDayYear
Date
Person 3 Relationship to Child
Person 4 Name

First NameLast Name
Person 4 Date of Birth

MonthDayYear
Date
Person 4 Relationship to Child
Person 5 Name

First NameLast Name
Person 5 Date of Birth

MonthDayYear
Date
Person 5 Relationship to Child
Person 6 Name

First NameLast Name
Person 6 Date of Birth

MonthDayYear
Date
Person 6 Relationship to Child
Person 7 Name

First NameLast Name
Person 7 Date of Birth

MonthDayYear
Date
Person 7 Relationship to Child
Person 8 Name

First NameLast Name
Person 8 Date of Birth

MonthDayYear
Date
Person 8 Relationship to Child
Family Information, Income, & Contacts
Living Address
Zip
City
State
County
Mailing Address (if different)
Zip Code
City
State
County
Parent/Guardian Phone Number Type

CellHomeWork
Phone Number
Please enter a valid phone number.
Name of Phone Owner
Additional Contact Phone Number Type (1)

CellHomeWork
Phone Number of Additional Contact (1)
Please enter a valid phone number.
Additional Contact Name (1)
Additional Phone Number Contact Type (2)

CellHomeWork
Phone Number of Additional Contact (2)
Please enter a valid phone number.
Additional Contact Name (2)
Parental Status (check one)

OneTwo
Primary Language at Home
Homeless Family

YesNo
Active Military

YesNo
Military Veteran

YesNo
Referred by Child Welfare Agency

YesNo
Employment Information

List employment history for the *last twelve months* for *both parent(s) and/or all guardian(s) of the child. YOU MUST LIST ALL PLACES OF EMPLOYMENT AND PROOF OF INCOME MUST BE PROVIDED FOR EACH.
(1) Parent/Guardian Full Name
(1) Employer
(1) Work Address)
(1) Work Phone Number
Please enter a valid phone number.
(1) Employment Beginning Date

MonthDayYear
Date
(1) Employment Ending Date

MonthDayYear
Date
(2) Parent/Guardian Full Name
(2) Employer
(2) Employer Work Address
(2) Employer Work Phone Number
Please enter a valid phone number.
(2) Employment Beginning Date

MonthDayYear
Date
(2) Employment Ending Date

MonthDayYear
Date
(3) Parent/Guardian Full Name
(3) Employer Name
(3) Employer Work Address
(3) Employer Work Phone Number
Please enter a valid phone number.
(3) Employment Beginning Date

MonthDayYear
Date
(3) Employment Ending Date

MonthDayYear
Date
(4) Parent/Guardian Full Name
(4) Employer Name
(4) Employer Work Address
(4) Employer Work Phone Number
Please enter a valid phone number.
(4) Employment Beginning Date

MonthDayYear
Date
(4) Employment Ending Date

MonthDayYear
Date
OTHER INCOME/PUBLIC ASSISTANCE:
If a household member receives, or has received any of the following during the last twelve months, proof must be provided with this application. Please check all boxes that apply.

SNAP (food stamps)Supplemental Security Income (SSI)TANF (TEA, Work Pays, Career Pathways)Unemployment BenefitsWIC
If drawing Unemployment Benefits, what date did you begin drawing on?

MonthDayYear
Date
If Receiving WIC, what is your WIC Household ID Number?
Medical/Disability/Special Needs:
Does your child have any special needs we should be aware of? Such as:

AsthmaFood Allergies Behavior concernsSpeech/Language DisordersDevelopmental DelayBehavior ConcernsODD, OCD, ADHDHearing ImpairmentVisual ImpairmentOrthopedic impairment or physical limitationsAutismCounseling from therapist
Please describe needs
List any medications your child is taking
Does your child receive special education or related services (have an IFSP or IEP) and/or receive treatment from a doctor/therapist for any of the above special needs?

YesNo
Additional Family Information
Does your family have any special circumstances, concerns or needs? Such as:

Abusive home situation, alcohol, drugs, child or spousal abuseApplicant is a foster childApplicant currently has an open child welfare case. Please see below to explainChild's parent is currently incarcerated (in prison/jail)Current address is a temporary living arrangement due to loss of housing or economic hardship (you will be contact to complete a Residency Questionnaire)First time parentParent/Guardian has a disability or special need.Parent/Guardian has no work experience or formal education (such as parenting classes, workshops or college courses) in childcareParent/Guardian is unemployed due to loss of job or being unable to workRecent death in family within last we monthsNoneOther
If Applicant currently has an open child welfare case, please explain:
If Parent/Guardian has a disability or special need. Please describe
Child is currently enrolled in or has previously attended a childcare center or preschool?

NoYes
If yes, where?
Do you have a child currently attending

Head StartABCOther preschool program
Is the child related to a staff member of F.A.C.T., Inc.? If so, please state who and what the relationship is
*This information will only be used for placement of the child if they are selected for enrollment.

Icertify that the above information is true. I understand that if any information is found to be false, my family's participation in this Agency's programs may be terminated, and that I may be subject to legal action. In addition, if my family participates in the ABC program and any information is found to be false, I shall be subject to repayment of funds to the Division of Child Care & Early Childhood Education and referral for prosecution. I also understand that this information is confidential and is accessible to me during normal business hours.
Signature of Parent/Legal Guardian

Clear
Printed Name of Parent/Legal Guardian
Today's Date

MonthDayYear
Date
Families and Children Together, Inc. - FACT, Inc.

is an Equal Opportunity Employer
Should be Empty:

Families and Children Together, Inc

Required Documentation

Applicant Information

The Primary Parent/Guardian Information

Secondary Parent/Guardian

Additional People Living in the Home

Family Information, Income, & Contacts

Employment Information

OTHER INCOME/PUBLIC ASSISTANCE:

Medical/Disability/Special Needs:

Additional Family Information

Families and Children Together, Inc. - FACT, Inc.