<p>Accepted date: ______App. Received by: ______EHS HB: ____ CB: ____ Date: ______HS HB: _____ CB: ______APPLICATION HEAD START / EARLY HEAD START </p><p>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.</p><p>CHILD INFORMATION</p><p>Are you currently enrolled in the EHS expectant mothers program? Yes No</p><p>Child’s Name: ______Date of Birth: ______Last First Middle Phone Number: ______Sex: Male / Female (circle one)</p><p>Address: ______City/State/Zip: ______</p><p>School District: ______County: ______</p><p>Primary Language Spoken in the Home: ______Social Security #: ______</p><p>Is this child a Foster Child? Yes No</p><p>Does this child currently receive Child Care Subsidy? Yes No</p><p>Insurance: None Medicaid Child Health Plus Private Other </p><p>PARENT/GUARDIAN INFORMATION</p><p>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</p><p>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</p><p>Family Type: Single Parent/Male Foster Parent Dual Custody Single Parent/Female Grandparent Two Parent Other: </p><p>Please list any other individuals living in your household (not previously listed): Name D.O.B. Relationship to child</p><p>Child’s Race: African American Asian Native American White Other </p><p>Is Child: Hispanic or Latino? Yes No </p><p>Highest Education Level achieved by all Household Members:</p><p>0-8 9-12(non-grad) HS Grad or GED 12+(some college) 2or 4 yr college grad Masters</p><p>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:______</p><p>______Parent/Guardian’s Signature Date</p><p>Referred by: ______</p><p>* 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</p><p>MG:forms:hsehsapp 3/14/10</p>