Rural CAP Child Development Program Year 17/18

RurAL CAP Child Development Program Year 17/18 Enrollment Application

Program applying for: □ Parents as Teachers □ Early Head Start □ Head Start □ Child Development Center

Community:

Child is transitioning from: □ EHS □ PAT □ Early Learning Environment □ None

Child Information Full First Name Full Middle Name Full Last Name Suffix

Birth Date Gender Social Security Number □ Male □ Female Race: □ Alaska Native □ American Indian □ African American / Black □ Caucasian / White (Choose all that apply) □ Asian □ Pacific Islander / Native Hawaiian Ethnicity: (Choose one) □ Hispanic □ Non-Hispanic

Child Primary language Child Secondary language: □ Little □ Moderate □ Proficient □ Little □ Moderate □ Proficient Parent / Guardian Information (or Anchorage DHSS PAT Adult)

Primary Legal Guardian: First and Last name Birth Date Gender Race Hispanic □ M □ F □ No □ Yes Primary Language: □ Translation or Interpretation Services Needed

Education level (Circle One) Employment status: (Choose one) Gr: ____ GED HSG COL AA BA MA □FT only □ FT Employed & School □ Seasonal □Training/School □PT only □ PT Employed & School □ Retired □Disabled □ Unemployed

Relationship to child: □ Parent/Guardian □ Grandparent □ Other Relative □ Foster Parent (attach letter) □ Other:______

Anchorage DHSS PAT Adult only: Do you have a diagnosed disability? □ No □ Yes □ I do not wish to disclose Secondary Legal Guardian: First and Last name Birth Date Gender Race Hispanic □ M □ F □ No □ Yes Primary Language: □ Translation or Interpretation Services Needed

Education level (Circle One) Employment status: (Choose one) Gr: ____ GED HSG COL AA BA MA □FT only □ FT Employed & School □ Seasonal □Training/School □PT only □ PT Employed & School □ Retired □Disabled □ Unemployed Relationship to child: □ Parent/Guardian □ Grandparent □ Other Relative □ Foster Parent (attach letter) □ Other:______Lives with Primary Parent/Guardian □ No □ Yes Family Information

Parental status: □ One Parent Family □ Two Parent Family □ Teen Parent (age 19 and under at time of birth)

Do you: (Choose one) □ Rent your home □ Own your home □ Neither Do you live in a shelter, transitional housing, motel, vehicle or move frequently between homes of relatives or friends: □ No □ Yes (If yes, attach housing form)

Is either parent or guardian: □ Active US Military □ Veteran of US Military □ Neither

Was your family referred for services by a child welfare agency? (Office of Children’s Services, Child in Transition, ICWA, etc.) □ No □ Yes Does your child Child Care Assistance SNAP/Food Stamps WIC Indian Health Services currently receive: □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes RurAL CAP Child Development Program Year 17/18 Enrollment Application Family Contact Information Mailing Address: Physical Address:

City: AK Zip Code ______City: AK Zip Code ______Primary Phone: Alternate Phone: □ Home □ Cell □ Work □ Home □ Cell □ Work

Able to receive text messages on primary phone? ? □ No □ Yes E-mail: USDA and this institution are equal opportunity providers and employers. Child’sParent/Guardians have the right to receive translation or interpretation services in their primary language as well as reasonable accommodations to Nameparticipate in the program. Birth Date Community:

Family Income (Parent(s)/Guardian(s) Only)

Does either parent/ guardian currently receive: □ TANF/ATAP □ Supplemental Security Income □ None Type of Income verified: □ Tax Return □ W-2 □ Supplemental Security Income □ Check Stubs (Previous 12 months) □ TANF / ATAP Total annual □ Unemployment Statements □ Adult PFD (Parent / Guardian PFD's only) □ Social Security Income income of family □ Other: ______□ No Income*: If you have no income, please complete a “No Income Statement” form $ Number of individuals related by blood, marriage or adoption, living in the home, Number of Adults supported by the parent/guardian's income (answer at right): Number of Children +

Total Number: = Verifying RurAL CAP Staff

Printed Name Signature Date

Child Health Information Primary Health Coverage/Insurance(Child & Anchorage DHSS PAT Adult): □ Denali Kid Care / Medicaid □ Private □ Other:______□ None Doctor/ Medical Clinic Name: Phone:

Dentist/ Dental Clinic Name: Phone:

Does your child have any diagnosed food* or medical allergies? □ No □ *Yes If yes, please explain:

* If your child has a food allergy, a completed “Medical Statement for Food Substitution" or other documentation, MUST be provided before we can make food substitutions. Do you have any health concerns about your child? Do you have any developmental concerns about your child? □ No □ Yes If yes, please explain: □ No □ Yes If yes, please explain:

Child Individualized Education Plan (IEP)/ Individualized Family Service Plan (IFSP)

Is your child currently being evaluated for an IEP or IFSP? □ No □ Yes Does your child have a current IEP or IFSP? □ No □ Yes RurAL CAP Child Development Program Year 17/18 Enrollment Application If yes, please attach copies of the: □ IEP or □ IFSP and □ Signed Release of Information Form

Enrollment Agreement I certify that this information is true and correct. I agree to promptly update my child and family’s information during my child’s enrollment with RurAL CAP. I agree to review this information every year. I agree to allow RurAL CAP to share my child’s information within RurAL CAP's early childhood programs. All information is kept strictly confidential and I may access it during normal business hours.

Parent/ Guardian signature : Date

Rural CAP Site Staff signature : Date

Central Office Staff Use Only

Priorit Income Parent Status Age Transition Disability Other Total Points y

Points

Concern Status Primary Condition IFSP/IEP Date MH/D Initials

Immunizations H/N Initials

□ Complete □ Needs □ Exempt □ Up-to-Date

Classroom Enroll Status Effective Date FSE/Specialist Initials

C D E H I J □ Accept □ Waitlist