Head Start/Early Head Start Program Application

Head Start/Early Head Start Program Application
Information of Child
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender*

MaleFemaleNon-Binary
Who does the child live with?*

Both ParentsMotherFatherLegal Guardian(s)Foster Parent(s)
Who has primary custody of the child?*

Both ParentsMotherFatherLegal Guardian(s)DHS
Are you enrolling another child into the program?*

YesNo
Information of Child 2
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender*

MaleFemaleNon-Binary
Who does the child live with?*

Both ParentsMotherFatherLegal Guardian(s)Foster Parent(s)
Who has primary custody of the child?*

Both ParentsMotherFatherLegal Guardian(s)DHS
Are you enrolling another child into the program?*

YesNo
Information of Child 3
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender*

MaleFemaleNon-Binary
Who does the child live with?*

Both ParentsMotherFatherLegal Guardian(s)Foster Parent(s)
Who has primary custody of the child?*

Both ParentsMotherFatherLegal Guardian(s)DHS
Is there a parent/guardian pregnant?*

YesNo
Are you interested in applying for Prenatal services? (proof of pregnancy is required)*

YesNo
Due Date*
Information of Parent/Guardian
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender*

MaleFemaleNon-Binary
Primary Language At Home*
English Proficiency*

NoneLittleModerateProficient
Do you need an interpreter?*

YesNo
Phone Number*
Please enter a valid phone number.
Text opt-in?*

YesNo
Email Address
example@example.com
Email opt-in?*

YesNo
Is the parent/guardian currently employed or unemployed?*

EmployedUnemployed
Parent/Guardian paid in cash the last 12 months? (**if no, please submit W2, tax return, unemployment benefits, child support award)*

YesNo
Living Address*

Street Address and Apartment #

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have an additional address for mailing or for pick up/drop off?*

MailingPick Up/Drop OffNone
Additional Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information of Additional Parent/Guardian
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender

MaleFemaleNon-Binary
Does the parent/guardian live with the family?*

YesNo
Is the parent/guardian currently employed or unemployed?*

EmployedUnemployed
Parent/Guardian paid in cash the last 12 months? (**if no, please submit W2, tax return, unemployment benefits, child support award)*

YesNo
Primary Language At Home
English Proficiency

NoneLittleModerateProficient
Do you need an interpreter?

YesNo
Phone Number
Please enter a valid phone number.
Text opt-in?

YesNo
Email Address
example@example.com
Email opt-in?

YesNo
Is your living address the same as family's?

YesNo
Living Address

Street Address and Apartment #

Street Address Line 2

CityState / Province

Postal / Zip Code
Answer the following questions as completely as possible. This will help us determine your eligibility.
Parental Status?*

SingleTwo Parent
Additional Family Information (check all that apply)*

Parent/Guardian currently enrolled in school/job trainingDomestic violence, sexual abuse, mental health, or substance abuseReferral from other programs within Community Action or other agenciesParent/Guardian is/was a teen parentParent/Guardian has been diagnosed with a medical conditionLack of childcareEnglish as a second languageTransitioning from another Head StartDeath of immediate family memberSibling in Head Start or Early Head StartHaving incarceration experience/deported parent/guardian/refugee familyNone
List additional children/dependents that are living in the home(non-applicants)
How many people are in your family?*
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Relationship to the child
Financially supported by the parent(s)/guardian(s)

YesNo
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Relationship to the child
Financially supported by the parent(s)/guardian(s)

YesNo
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Relationship to the child
Financially supported by the parent(s)/guardian(s)

YesNo
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Gender
Relationship to the child
Financially supported by the parent(s)/guardian(s)

YesNo
Eligibility Information

Answer the following questions as completely as possible. This will help us determine your eligibility.
Check all that apply (**please submit a TANF award letter, or SNAP award letter, or SSI award letter):*

Receiving SNAP (food stamps)Receiving TANF (cash assistance)Receiving Supplemental Security Income (SSI)None
Current housing situation:*

Own/RentSharing a home with family or friends due to economic hardshipLiving in a motel/hotel, trailer park, or campgroundIn a shelter (family/domestic violence-safe house/transitional shelter)Primary nighttime residence not ordinarily used as a regular sleeping accommodation (e.g. park benches)In a car, park, public space, abandoned building, substandard housing, or bus/train station
Is your child/ren receiving services through Northwest Regional Education Service District (NWRESD) and/or have an Individual Family Service Plan (IFSP)?*

YesNo
Name of the Child/ren*
Are you receiving services through Lifeworks Northwest?*

YesNo
Name of the Child/ren*
Are you receiving services through other agencies?*

YesNo
Name of the Child/ren*
How did you hear about Community Action Head Start and Early Head Start?*

Community event/resource fairWord of mouthFlyerInformation through mailSchool districtWICDHSSocial mediaDoctor/Dental officeOther
Other (specify)*
Upload Eligibility Information

We will need the following information if it applies to your family to process your child's application.
Birth Record

Example: Birth certificates, hospital certificates, immunizations, or passport
Cancelof
Income Documentation

Example: W2, tax return, TANF/SNAP award letter, SSI award letter, child support
Cancelof
Foster Placement Letter

Cancelof
Guardianship Letter

Cancelof
Proof of Pregnancy (applies when you are applying for prenatal services)

Cancelof
I affirm that to the best of my knowledge, all the information that I have provided is complete and correct. I understand that if I deliberately misrepresent my family circumstances, my family may not be eligible for services. By signing this application, I authorize Community Action Head Start to release this information to Early Learning Washington County, Beaverton School District, Hillsboro School District, Tigard/Tualatin School District, Sherwood School District, Oregon Child Development Coalition, NWRESD, LifeWorks Northwest, Other Head Start programs, DHS and programs within Community Action Organization for enrollment purposes.
Parent/Guardian Signature: *

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Declaration of Income/No Income
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Are you enrolling another child into the program?*

YesNo
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Are you enrolling another child into the program?*

YesNo
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Please complete the questions below:
Declaration of Income without Proof of Documentation

This is to be completed if you are paid in cash or cannot provide proof of your income.
Parent/Guardian Name*

First NameLast Name
Did you receive income in the last 12 months?*

YesNo
How much did you receive in the last 12 months?*
What was the source of your income?*
Additional Comments:
Declaration of Income without Proof of Documentation

This is to be completed if the additional parent/guardian was paid in cash or cannot provide proof of your income.
Additional Parent/Guardian Name*

First NameLast Name
Did you receive income in the last 12 months?*

YesNo
How much did you receive in the last 12 months?*
What was the source of your income?*
Additional Comments:
Declaration of NO Income

If no to having income in the last 12 months, how have you paid for the following costs:
Parent/Guardian Name*

First NameLast Name
Did you receive income in the last 12 months?*

YesNo
How did you buy food?*
How did you pay rent?*
How did you pay bills or utilities?: *
Declaration of NO Income

If the additional parent said no to having income in the last 12 months, how have you paid for the following costs:
Additional Parent/Guardian Name*

First NameLast Name
Did you receive income in the last 12 months?*

YesNo
How did you buy food?*
How did you pay rent?*
How did you pay bills or utilities?: *
I certify that all the above information is true and correct. I understand that this information will be used to determine my eligibility for the Community Action Head Start program. I understand that if I provide false information, my participation in the program may be denied or terminated.
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Office Use Only
Enrollment Assistant Name: _________________________________________
Enrollment Assistant Signature:

_____________________________________
Date: __________
ERSEA Supervisor Signature:

____________________________________
Date: __________
Should be Empty:

Head Start/Early Head Start Program Application

Information of Child

Information of Child 2

Information of Child 3

Information of Parent/Guardian

Information of Additional Parent/Guardian

Eligibility Information

Upload Eligibility Information

Declaration of Income/No Income

Declaration of Income without Proof of Documentation

Declaration of Income without Proof of Documentation

Declaration of NO Income

Declaration of NO Income