Gateway Head Start At-Risk Verification Form
Parent/Guardian First and Last Name
First Name
Last Name
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's First and Last Name
First Name
Last Name
Child's Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Select the one that applies to your home (Choose only one)
Natural Parent
Foster Parent
Kinship care
Other
Does your family receive food stamps?
Yes
No
Does your family receive KTAP?
Yes
No
Do you receive Temporary Assistance For Needy Families (TANF)?
Yes
No
Does anyone in your home receive Supplemental Security Income?
Yes
No
Are you sharing a house with others due to economic hardship?
Yes
No
Name of Parent(s)/Guardian(s) Please check "Y" if the parent/guardian resides in the home with the child and check "N" if they do not. (Please put MONTHLY INCOME in the chart below)
Rows
Full Name
Gross Income
Welfare, Child Support, Alimony
Pensions, Retirements, Social Security
Other Income
Y
N
First and Last
First and Last
People living with you
People living with you
I, the applicant, agree with the following statements
By signing below, you certify that the above information is accurate and all income has been reported. You understand that this information will be used to determine eligibility for Head Start/Preschool and before acceptance into either program you must complete additional paperwork and present proof of income that satisfies specific program requirements.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Applicant
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