Urban Aboriginal Head Start Program - Application Form
?iihmisuk taatna?is - Treasure our Young Ones
Application Date:
*
-
Month
-
Day
Year
Date
ENROLLING CHILD'S INFORMATION:
Child's Full Legal Name:
*
Date of Birth:
*
-
Day
-
Month
Year
Date
Do you identify your child as Indigenous?
*
Yes
No
If yes, please check one of the following?
First Nations
Metis
Inuit
If First Nations, which community (band)?
FAMILY/CAREGIVER INFORMATION:
Enrolling Parent/Caregiver Name:
*
Home Phone:
*
Format: (000) 000-0000.
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
*
example@example.com
Alternate Parent/Caregiver Name:
Do you have the same address?
Yes
No
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Does any of your family members speak your traditional language in your home?
Yes
No
If yes, what language?
Do you support your child being exposed to a variety of cultures and languages while in the Head Start Program?
Yes
No
Dates you would like your child to be enrolled.
Rows
Enrolled
Monday
Tuesday
Wednesday
Thursday
Friday
Back
Next
Please check the areas below that you feel fit your family's and child's needs:
Culture and Language
Nutrition
Education
Social Support
Health Promotion
Parental & Family Involvement
Were you referred to the Head Start Program?
*
Yes
No
If yes, please check one or more on the list below:
Family Support Worker
Counselor
Early Childhood Development Worker
Support Worker
Social Worker
Other
VOLUNTEERING IN THE HEAD START PROGRAM:
A very important part of supporting your child's development is your involvement in the activities and contributions to the program. ?iihmisuk ?aatne?is - Head Start Program strongly encourages the involvement of all families within our program.
Are you willing to volunteer in our Head Start Program?
*
Yes
No
If yes, please check off the opportunities you would most likely be able to help with:
Participation on Field Trip Outings
Sharing cultural customs/traditions/recipes
Sewing / Knitting / Weaving
Carving / Woodwork
Singing
Drumming
Language
Dancing
Gardening
Meal and Snack times
Other
How many days of the week can you volunteer?
How many hours per day can you volunteer?
Parent or Guardian Signature
Submit
Should be Empty: