Benton Franklin Head Start

BENTON FRANKLIN HEAD START Child Application Instruction Sheet for Child Application

Benton Franklin Head Start partners with families in the community to promote school readiness through comprehensive services for young children and their families.

Early Head Start and Head Start programs serve pregnant women and children ages birth to 5 The information you provide on this application is important. ALL INFORMATION RECEIVED WILL BE KEPT CONFIDENTIAL. We must have ALL of the information listed below in addition to a completed Benton Franklin Head Start Child Application to determine your child’s eligibility.

Please provide a copy of the following: Proof of Birth: Birth Certificate, Hospital Record, or other official record of child’s birth. Immunization: Child’s current shot record. Medical Insurance: Child’s current medical services card and/or insurance card. Agency Referral: Letter from agency referring your child (if applicable). IEP/IFSP: Individualized Education Plan/Individualized Family Service Plan (if applicable). Income:  Documentation of currently receiving and on-going:  SSI (Supplemental Security)  TANF (Cash) – Benefit History from caseworker,  Foster Care – Foster Care Warrant Letter and letter from Social Worker when child was placed in foster care. OR  Documentation of previous years income:  Income Tax Return (1040), W-2 Forms (all)  Pay stubs, financial aide, military pay, written statements from employers  Unemployment - print out of payments from the Employment Security Office  Child Support/alimony - letter from Child Support Enforcement (CSE). OR  Income for the last 12 months  Pay stubs, financial aide, military pay, written statements from employers  Unemployment - print out of payments from the Employment Security Office  Child Support/alimony - letter from Child Support Enforcement (CSE).

 Income must be for the immediate family members of the child applicant living in the same household.

Child’s Name: Use your child’s legal name that corresponds with the Birth Certificate or Hospital Record. Address/Phone #: It is your responsibility to notify Benton Franklin Head Start of any changes to your address and/or phone number. Benton Franklin Head Start does not provide transportation for children. Parents/Guardians are responsible for the transportation of their children.

Please mail or drop off your Application 13/14 Family Income Poverty Guidelines at one of the following sites: Family Size 100% Central Pasco 1 $11,490 3203 W. Sylvester 2 $15,510 Pasco, WA 99301 3 $19,530 509.542.9688 4 $23,550 5 $27,570 The Children’s Center 6 $31,590 1549 Georgia Ave. S.E., Suite B 7 $35,610 Richland, WA 99352 8 $39,630 509.735.1062 For each additional person add $4,020

Child’s Name BFHS 1.13 Page 1 of 6 EN006 BENTON FRANKLIN HEAD START Child Application (First Name) (MI) (Last Name) Child’s Home Address (City) (State) (Zip) Mailing Address (City) (State) (Zip) Date of Birth Age  Male  Female Does this child speak English at home?  Yes  No What is this child’s primary language? What is this child’s secondary language? Child’s Ethnicity:  Hispanic or Latino Origin  Non-Hispanic/Non-Latino Origin Child’s Race:  American Indian/Alaska Native  Asian  Black or African-American  Native Hawaiian/Pacific Islander  White  Bi/Multi-racial  Unspecified  Other (Mexican, Mexican American, European, etc.) Is this child enrolled or on another agency’s waitlist for preschool? Yes  No

If yes, which agency ______Do we have permission to contact this agency? Yes  No 

Mother’s Information: Living in the home? Yes  No  Married? Yes  No  Spouses Name Mother full name Address Primary Language Home Phone # Work # Other # Email address: Ethnicity Race Do you speak English? Yes  No Do you read English? Yes  No Training/School Homemaker Unemployed Employed-If yes Employers Name Less than High School education High School graduate/GED Some College/Vocational School  Bachelor’s or higher degree

Father’s Information: Living in the home? Yes  No  Married? Yes  No  Spouses Name Father full name Address Primary Language Home Phone # Work # Other # Email address: Ethnicity Race Do you speak English? Yes  No Do you read English? Yes  No Training/School Homemaker Unemployed Employed-If yes Employers Name Less than High School education High School graduate/GED Some College/Vocational School  Bachelor’s or higher degree

Please complete if child does not live with biological parent (Guardians) Please submit proof of guardianship __ (First Name) (Last Name) (First Name) (Last Name) Relationship to child Relationship to child Address Address Home Phone # Work # Home Phone # Work # ______Other # Primary Language Other # Primary Language __ Ethnicity ______Race Ethnicity ______Race Email address: Email address: Training/School Homemaker Unemployed Employed Training/School Homemaker Unemployed Employed Employers Name Employers Name Less than High School education High School graduate/GED Less than High School education High School graduate/GED Some College/Vocational School  Bachelor’s or higher degree Some College/Vocational School  Bachelor’s or higher degree Do you speak English? Yes  No Do you speak English? Yes  No Do you read English? Yes  No Do you read English? Yes  No

ALTERNATE CONTACT PERSON: If we are unable to contact you, whom may we call that is not living in the child’s household? Name Relationship to child Language Phone # Work # Cell # BFHS 1.13 Page 2 of 6 EN006 BENTON FRANKLIN HEAD START Child Application

Please list child applicant's immediate family living in the home; include self and child applying as well. If you need more lines for additional family members; please attach an additional page and include all of the following information. (if necessary)

Name Date of Birth Relationship Is financially supported to Child by parent/guardian Yes  No 

Yes  No 

______Yes  No 

Yes  No 

______Yes  No 

EARLY HEAD START APPLICANTS (Pregnancy - up to Age 3) Please check preference: EHS is a Full Year Program Home-based Model at your home once a week for 90 minutes

HEAD START APPLICANTS (Age 3 by August 31st to Age 5) Please CHECK Session Preference: AM (Morning-only) PM (Afternoon-only) Either AM or PM Please CIRCLE the order of sites you are willing to transport your child to. (1-First Choice, 2-Second Choice, 3-Third Choice) Central Pasco Martin Luther King (MLK) Jefferson Children’s Center Marcus WhitmanBenton City 3203 W Sylvester 205 S. Wehe 1525 Hunt Ave 1549 Georgia Ave 1704 Gray St. 313 #B Third St. Pasco Pasco Richland Richland Richland Benton City 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3 1, 2, 3

1. a. Please mark the services your family is receiving (mark all that apply) Women Infant Children (WIC) Dept. of Developmental Disabilities (DDD) SNAP (Food Stamps) Public Housing Assistance Childcare Subsidy Medical Services Card ARC  Other b. Please mark the financial assistance your family is receiving: (mark all that apply)

Supplemental Security Income (SSI) Social Security (SSA) Financial Aid

BFHS 1.13 Page 3 of 6 EN006 BENTON FRANKLIN HEAD START Child Application Unemployment Temporary Assistance to Needy Families (TANF) (cash only) Child Support Military Pay Foster Care/Adoption Subsidy Other

Circle Correct Official Answer Use Only 2. Do you have childcare? If yes, what type  Family Child Care  Child Care Center or classroom Yes No  At home or another home with relative/adult  Public School/Pre-K program

If not, are you having a problem finding childcare? Yes No

3. Is dependable transportation available to your family? (car, bus. etc.) Yes No

4. In the last 12 months, has there been a time when you needed assistance to feed your family? Yes No

5. In the last 12 months, has your family had appropriate clothing for the weather? Yes No

6. In the last 12 months, has your water/power been turned off or has your bill been delinquent for 60 days or more? Yes No

7. Do you have support of family and/or friends in this community? Yes No

8. Is this child being referred to this program by another agency/provider? Yes No

( Physician  School district  Head Start  Early Head Start  DSHS  Health District,  Foster Care  Child Welfare (CPS), etc) Must attach referral letter

9. Does this child have a diagnosed chronic health condition? Yes No

If yes, what is the condition ______

10. In this household, do any of this child’s parents/guardians or siblings, have a diagnosed Yes No chronic health condition?

If yes, what is the condition ______

11. Is this child currently on an Individual Family Service Plan (IFSP) or Individual Education Plan (IEP) (Please attach) Yes No

12. Does this child reside with only one parent/guardian? Yes No

13. Is this child in the care of someone other than the parent/guardian? If Yes:  foster care  grandparent  aunt or uncle  extended family  Other Yes No

14. Does this child and parent/guardian live with extended family? (grandparent, aunt, uncle, etc.) Yes No

15. Does this child have medical insurance? (medical services card, private insurance, etc.) Yes No

16. Does this child have a doctor or medical clinic? Yes No

17. Does this child have a dentist? Yes No

18. In this child’s household, is either parent/guardian currently unemployed? Yes No

19. Are either of the child’s parents currently serving in the United States military on active duty? Yes No BFHS 1.13 Page 4 of 6 EN006 BENTON FRANKLIN HEAD START Child Application

20. Are either of this child’s parents/guardians able to speak English? Yes No

21. If this child speaks English as a second language, how well do they speak English?  Very Well  Well  Not Well  Not at all

22. Do you consider your family homeless? If yes, you must fill out a homeless questionnaire. Yes No

Circle Sub Total Correct Official Answer Use

23. Has your family immigrated to the United States within the last 5 years? Yes No ______

24. Did this child’s mother receive less than 3 months of prenatal (doctor) care with this child? Yes No ______

25. Was the child’s mother or father 19 or younger when this child was born? Yes No ______

26. Did your doctor have any concerns with your pregnancy/birth of this child? Yes No  traumatic birth  premature (36 weeks or less)  low birth weight  exposure to drugs or alcohol  high risk pregnancy  other ______

27. Has the child’s family been involved with Child Protection Services (CPS) within the last 5 years? Yes No

28. Has anyone in the child’s immediate family had a significant loss within the last 5 years? Yes No death divorce separation parent incarceration other

29. Has anyone in this child’s household abused drugs or alcohol since this child’s birth? Yes No ______ Has received treatment  Currently receiving treatment  Is in need of Treatment

30. Has anyone in the immediate family experienced domestic violence since this child’s birth? Yes No

31. Is this child receiving or in need of counseling? Yes No  Is receiving counseling  Is in need of counseling

32. Is anyone in this child’s household receiving or in need of counseling? Yes No  Is receiving counseling  Is in need of counseling

33. Is either parent/guardian unable to read or write? Yes No

34. Does anyone living in the home use tobacco products? Yes No

35. Is this child exposed to any gang activity? Yes No _

Sub Total ______

GRAND TOTAL ______

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ~~ Circle Correct Official I understand that in order for Benton Franklin Head Start to process my child’s application Answer and determine Use eligibility, Only I must complete all the questions on the application and attach all required documentation. I believe the attached verification of my/our annual income is true and complete to the best of my knowledge. I understand the falsification of any statement or documents will jeopardize my child’s eligibility in the Early Head Start/Head Start program.

BFHS 1.13 Page 5 of 6 EN006 BENTON FRANKLIN HEAD START Child Application Parent/Guardian Signature Date Benton Franklin Head Start does not discriminate on the basis of race, color, national or ethnic origin, religion, gender, age, disability, or any other characteristic protected by law. Section 645(a) of the Head Start Act states that “children from low-income families shall be eligible for participation in programs assisted under this sub chapter if their families’ incomes are below the poverty line, or if their families are eligible for public assistance.”

Performance Standards: 1305.4(b)(1), 1305.6(a), 1305.6(b), 1305.6(c), 1305.6(d)

BFHS 1.13 Page 6 of 6 EN006