Head Start Eligibility Verification Form

1. Child’s name

2. Child’s date of birth

Date

3. Is this child eligible to participate in the program?

4. Type of eligibility interview conducted:

5. Indicate the applicable eligibility criterion for this child:

*45 CFR 1302.12(c 2) specifies that a program may enroll a child who would benefit from services but does not meet other eligibility requirements provided that these participants only make up to 10 percent of a program’s enrollment or 49 percent in the case of AI/AN programs as described in 45 CFR 1302.12(e)

**45 CFR 1302.12(d) specifies that a program may enroll an additional 35 percent of participants whose families do not meet any other eligibility criterion and whose incomes are below 130 percent of the poverty line.

6. What documentation was used to determine eligibility and is included as part of the eligibility determination record?

7. Staff signature

Date

8. Staff name

Title