Clone of NCO Head Start Child Development Program Application - Head Start/Early Head Start (OVER ONE YEAR OF AGE)

NCO Head Start Child Development Program Application - Head Start / Early Head Start

Please complete a separate application for each child.
Dear Family,

Thank you for your interest in the Head Start Child Development Program. Please complete the application in full along with the following documents attached:
- Recent proof of your family’s income (Cash Grant Action Notice or Passport to Services from Social Services, pay stubs for one whole month, Social Security payment notice, written verification from your employer or person providing for you at this time, your mostrecent W-2or Tax return).
- Proof of your child’s age (birth certificate, DSS Passport to Services, Baptismal Certificate, Medi-Cal Card)
- Copy of your child’s up-to-date immunization record. California law states that children cannot attend school without proof of up-to date immunizations.
(Note: Your child’s application will not be processed without these documents or if immunizations are not up to date)

We welcome children with special needs, food allergies and other medical conditions. Please note that additional follow up may be requested from agencies and/or medical providers currently working with your child in order to ensure that the program meets your child’s needs.

We use a point system that gives selection priority in certain situations, so it is important to answer each question on the application.

If you have questions about the application, need help in returning it, or would like copies made of your documents, please call us at (707) 462-2582.

After processing your application, we will send a letter about your child's application status. Please note your application will only be consideredfor the program year you are applying for. Thank you for choosing the NCO Head Start Child Development Program as part of your child's early learning experience. We look forward to meeting you and your child.

HEALTH HISTORY AND PARENT MEDICAL AUTHORIZATION
Child's Name:

First NameLast Name
Child's Date of Birth:

MonthDayYear
Date
Parent's Name:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Message Phone:
Please enter a valid phone number.
Name of Child's Doctor (or clinic): *
Name of Child's Dentist (or clinic): *
Medical Insurance:*
Dental Insurance:*
Permission to Use Fluoride Toothpaste

The Head Start program brushes children’s gums and/or teeth daily. For children over 1 year old, fluoride toothpaste is used.
Do you authorize NCO Head Start to use fluoride toothpaste with your child?*

YesNo
Do you authorize fluoride varnish during site dental exams?*

YesNo
RELEASE OF MEDICAL INFORMATION:
I agree to the release of medical information between Head Start Child Development Program and my child’s Medical Providers, Dental Providers, the local Health Department and the WIC program for the purposes of coordination to provide the best possible health services to my child, and to meet the requirements for documentation of such services of the Head Start Child Development Program. This permission for release of information is in effect from the date of signing this form and during the period of time my child is enrolled in NCOHSCDP and is pursuant to HIPAA and California law and includes, but is not limited to, any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or any other covered health care provider. I understand this written consent is voluntary and subject to revocation at any time.
Today's Date:*

MonthDayYear
Date
Parent/Guardian Signature*

Clear

If you have any attachments to add, please do so here:
Don't forget!
We require copies of the following for processing:
- Recent proof of your family’s income (Cash Grant Action Notice or Passport to Services from Social Services, pay stubs for one whole month, Social Security payment notice, written verification from your employer or person providing for you at this time, your mostrecent W-2or Tax return).
- Proof of your child’s age (birth certificate, DSS Passport to Services, Baptismal Certificate, Medi-Cal Card)
- Copy of your child’s up-to-date immunization record. California law states that children cannot attend school without proof of up-to date immunizations.
If you need assistance with this, please call our office at 707-462-2582.
Files allowed include: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif.

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NCO Head Start Child Development Program Application - Head Start / Early Head Start

HEALTH HISTORY AND PARENT MEDICAL AUTHORIZATION

HEALTH ASSESSMENT

If you have any attachments to add, please do so here: