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  • 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 all sections of the attached six‑page application and return them along with the following documents: 
     
    Required Documents
    1. Proof of Family Income: Please provide recent documentation, such as:

    Cash Grant Action Notice or Verification of Services (Social Services) 
    Pay stubs for one full month 
    Social Security award letter 
    A written statement from your employer or the person currently supporting you 
    Your most recent W2 or tax return 

    2. Proof of Your Child’s Age-Accepted forms include: 

    Birth certificate 
    DSS Passport to Services 
    Baptismal certificate 
    MediCal card  

    3. Up-to-Date Immunization Record: A copy of your child’s current immunization record is required. California law requires that children have up-to-date immunizations to attend school.

    Please note: We cannot process your child’s application without all required documents or if immunizations are not current.

    Submitting Your Application 
    We use a point based system that prioritizes certain circumstances. For accurate evaluation, please ensure all questions are answered, and that the application is signed and dated.

    What Happens Next 
     After your application has been processed, you will receive a letter notifying you of your child’s application status. Please note that your application will be considered only for the program year you are applying for.  
     
    Thank you for choosing the NCO Head Start Child Development Program to be part of your child’s early learning journey. We look forward to meeting you and your family.  

    Please Note
    Healthy and nutritious meals are provided to all children, free of charge. Children with food allergies and/or disabilities have a right to free accommodations. We provide these services upon request, and work with families to obtain the required documentation. This institution is an equal opportunity provider.

    Please call us with any questions at (707) 462-2582 or from outside Ukiah at 1-800-326-3122



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  • We are happy to help you with this application at the Central Office or your local site - just ask! 

  • About Your Child

  • Child's Birth Date:*
     - -
  • Child's Sex:*
  • Child's Race:*
  • Does your child have an open case with Child Protective Services?*
  • Is your child enrolled in the young parent program?*
  • Child's Disability Status:*

  • About Your Child's Parent/Guardians

  • 1. Which applies to your home? If single, please answer question 2.*
  • 2. If single parent, do you have shared custody? If yes, please attach proof.
  • Does Parent/Guardian live in the home?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race:*
  • Preferred oral language:*
  • Preferred written language:*
  • What is the best way to contact you?:*
  • Does Parent/Guardian live in the home?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Race:
  • Preferred oral language:
  • Preferred written language:
  • What is the best way to contact you?:

  • About Your Child's Home

  • Rows
  • Are any of the above children currently enrolled in Head Start or Early Head Start?
  • Are you or your child related to anyone employed by NCO Head Start Child Development Program?*
  • Is your child receiving specialized services from other agencies?*
  • Do you currently receive any of these benefits?

  • Put a check mark in any and all situations that currently apply to your family

  • Housing
  • Parents and Family
  • Do any of these situations apply to your child?

  • About Our Program

  • How did you hear about our program?*

  • Check the boxes below for classes that you are interested in. 

    EARLY HEAD START

    (Infant and toddler program)

  • Ukiah

  • HEAD START 

    (Preschool program for ages 3 - 5)

     Mendocino County

  • Ukiah

  • Lake County

  • Clearlake

  • The HSCDP does not discriminate on the basis of gender, sexual orientation, ethnic group identification, race, ancestry, national origin, religion, color, mental or physical disability, or immigration status in determining which children are served.

    I certify this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand the information in this application will be held in strict confidence within the agency and is accessible to me during business hours. This information will not be released without my written consent.

  • Today's Date:*
     - -

  • HEALTH HISTORY AND PARENT MEDICAL AUTHORIZATION

  • Child's Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 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.

     

  • I authorize NCO Head Start to use fluoride toothpaste with my child.*
  • I authorize the fluoride varnish during site dental exams.*
  • Is your child currently taking fluoride supplements?*

  • 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:*
     - -

  • HEALTH ASSESSMENT

  • Instructions: Please answer the questions “yes” or “no” or by writing in the requested information. To expediate the enrollment process if you answer yes to any of the questions, follow-up will be required by the Health Specialist and/or the Nutrition Coordinator. In some cases, paperwork from the doctor will be required before the child can attend school. All information is confidential. If you have any questions, please call (707) 462-2582 or (800) 326-3122.

  • Are there any foods your child cannot eat for medical reasons? If yes, please explain.*
  • Does your child have any FOOD allergies? If yes, please explain.*
  • Is there any food(s) your child should not eat for religious or personal reasons? If yes, please explain.*
  • Does your child have any allergic reactions to any of the following? Medications or shots, animals / insects, other? If yes, please answer the next question and please explain:*
  • Which of these does your child have an allergic reaction to? (if applicable)
  • In the past 6 months, has your child recently been hospitalized or operated on? If yes, when, and please explain:*
  • In the past 6 months, has your child recently had any serious accidents or illnesses? If yes and please explain:*
  • Does your child need any special devices or adaptive equipment, or require any changes to the environment for health, safety, or comfort? If yes, please describe.*
  • Has your child been diagnosed with any medical conditions? If "yes", please answer the next following questions.*
  • Is your child currently taking medication for this condition?
  • Will your child need his/her medication at school?
  • Is your child taking any prescription or over the counter medication regularly?*
  • Date*
     - -

  • 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.

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