Head Start / Early Head Start

Accepted date: ______App. Received by: ______EHS HB: ____ CB: ____ Date: ______HS HB: _____ CB: ______APPLICATION HEAD START / EARLY HEAD START

Please be advised this application is strictly confidential. The Head Start/Early Head Start Program of Cortland County has a non- discriminating policy concerning admission of children in regards to race, religion, sex, national origin, or disability.

CHILD INFORMATION

Are you currently enrolled in the EHS expectant mothers program? Yes No

Child’s Name: ______Date of Birth: ______Last First Middle Phone Number: ______Sex: Male / Female (circle one)

Address: ______City/State/Zip: ______

School District: ______County: ______

Primary Language Spoken in the Home: ______Social Security #: ______

Is this child a Foster Child? Yes No

Does this child currently receive Child Care Subsidy? Yes No

Insurance: None Medicaid Child Health Plus Private Other

PARENT/GUARDIAN INFORMATION

Name: Name: ______Relationship to Child: Relationship to Child: ______Sex: Male Female Sex: Male Female Address: Address: ______Date of Birth: Date of Birth: ______Phone: ( ) _____ Phone: ( )______E-Mail Address: ______E-Mail Address: ______Place of Employment: Place of Employment: ______Work Phone: ______Work Phone: ______Can we call you at work? Yes No Can we call you at work? Yes No

Current Services: Head Start/EHS Energy Services WIC CDPAP Family Devel. Requests Info On: Head Start/EHS Energy Services WIC CDPAP Family Devel. HOUSEHOLD INFORMATION

Family Type: Single Parent/Male Foster Parent Dual Custody Single Parent/Female Grandparent Two Parent Other:

Please list any other individuals living in your household (not previously listed): Name D.O.B. Relationship to child

Child’s Race: African American Asian Native American White Other

Is Child: Hispanic or Latino? Yes No

Highest Education Level achieved by all Household Members:

0-8 9-12(non-grad) HS Grad or GED 12+(some college) 2or 4 yr college grad Masters

FINANCIAL INFORMATION Source of Income: Employment ( $ please circle one: weekly, monthly, yearly) SSI (Supplemental Security Income) TANF (including Public Assistance, Food Stamps, Medicaid, Daycare Subsidy) Other: Directions to home:______

______Parent/Guardian’s Signature Date

Referred by: ______

* Please mail or bring this completed application form to: CAPCO Head Start/Early Head Start 32 North Main Street Cortland, NY 13045 OR CALL (607) 753-6781 Application Updated for Re-Enrollment

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