Please answer all questions. You will be notified of eligibility after your application has been reviewed. Eligibility is determined by family income, child's age and/or child's special needs.  Income eligibility guidelines are determined by the U.S. Department of Health and Human Services.  

If you have any questions or need assistance completing the application please contact our office.

Child's Name 
First:   Middle:  Last:

Female  Male  Date of Birth:  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year

Home Address: 

Email Address: 

Phone Number: 

Mailing Address (if different than above): 

If no telephone number, please list someone we may contact to reach you:

School District where you live: 

County where you live: 

Child's Race/Ethnicity (this item is only for data reporting, it is entirely voluntary):

Primary Language (this item is only for data reporting, it is entirely voluntary):

Childcare Location (Name, Address, Phone):
:  

Has your child been in an Early Head Start/Head Start Program Before?
Yes  No  If Yes, when & where? 

Does your child have any special needs or health problems? Yes  No
If yes, please describe: 

Is your child receiving special services or currently on an IFSP/IEP? (For example:  medical, speech therapy, physical therapy, occupational therapy, counseling, etc.)  Yes  No       
If Yes, who is providing these services?

Parent/Guardian's Name:

Female  Male  Date of Birth:  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year

Place of Employment/Phone:    
Full Time  Part Time

Parent/Guardian's Name:

Female  Male  Date of Birth:  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year

Place of Employment/Phone:    
Full Time  Part Time

Child lives with:  Both Parents  Father  Mother Other 
If other, please specify: 

Marital Status:  Married  Single  Divorced  Separated 

Number of children in household:  (please list below)

First:   Last: Birth date:

First:   Last: Birth date:

First:   Last: Birth date:

First:   Last: Birth date:

First:   Last: Birth date:

First:   Last: Birth date:

Is any member of this family pregnant?  Yes  No  If Yes, whom and date due? 

Were your referred to this program?  Yes  No  If Yes, by whom?

What is your drinking water source?  Well  Rural  City

Many families receive services or financial assistance from other programs and agencies.  Do you receive any of the following?  (please check all that apply)

Medical Insurance:

Dental Insurance: 

Non-Discriminatory Clause:  It is the policy of USD Early Head Start/Head Start to not discriminate on the basis of race, sex, age, color, national origin, or disabilities in the provision of services and employment.

Confidentiality Statement:  Information shared with USD Early Head Start/Head Start will be kept strictly confidential unless its release is authorized in writing.  These forms will be maintained in locked files.

To accelerate the enrollment process, please provide the following to the program:

• A copy of your child's immunizations.
• Some form of income verification (for example: income tax return, pay stubs, financial award letter, child support, alimony, TANF, W-2, etc.).