ECEC Application Revised

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1 Salt River Pima-Maricopa Indian Community Early Childhood Education Programs Mailing Address: 10, 005 E. Osborn Road Physical Address: 4815 N. Center Street Scottsdale, AZ Phone: Fax: Thank you for applying to the Salt River Early Childhood Education Center. Submit this completed application along with the required documents to the Enrollment office and your child s eligibility will be determined. If your child is selected for enrollment, you will be notified by mail and/or phone. If there are no vacancies, your child will be placed on the waiting list. Program options include: Infant Toddler: serving pregnant women > 2 years old School hours: 9:00 a.m. 1:00 p.m. Child must live in the SRPMIC Home-based option available Before/After School program requirements: Child must be enrolled in a federally recognized tribe Parents/guardians must be working or in school/job training full time (working requirement is waived for children in protective care) Parents may not have an outstanding bill at ECEC Fees are based on family size/income level Parent co-payment required (fees waived for children in protective care) Preschool: serving 3 and 4 year olds School hours: 9:00 a.m. 1:00 p.m. Child must live in SRPMIC OR be enrolled in the SRPMIC (Tribal Preschool only) Before/After School program: Hours: 7:00 a.m. 6:00 p.m. (child must attend 9:00 a.m. 1:00 p.m.) Child must be enrolled in a federally recognized tribe Child must live in Mesa, Tempe, Scottsdale, or Phoenix (including SRPMIC) Parents/guardians must be working or in school/job training full time (working requirement is waived for children in protective care) Parents may not have an outstanding bill at ECEC Fees are based on family size/income level Parent co-payment required (fees waived for children in protective care) Submit the following documents with this completed application: REQUIRED: Proof of Income o Last two consecutive paycheck stubs, proof of per capita income, lease income, SSI, court order child support/spousal maintenance, unemployment compensation, grant/loan statement, regular insurance or annuity payments, TANF benefit statement o Written verification of employment must be submitted for those who are self-employed, have not yet received paychecks, or receive payment in cash REQUIRED: School or job training schedule (if using school status for Before/After School program eligibility) REQUIRED: Child s tribal ID (for Before/After School program) REQUIRED: Court order/custody papers if applicable Child s birth certificate Current immunization record Copy of child s last physical exam (child must have a physical exam within 45 days of entry or provide a copy of physical exam within the last 12 months

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3 Select Program Option: [ ] ECEC { } Regular school hours: 9:00 a.m. 1:00 p.m. { } Before/After school hours: 7:00 a.m. 6:00 p.m. (Must attend 9:00 a.m.-1:00 p.m.) [ ] Home-based (children under 3 years old and pregnant women living in the SRPMIC only) [ ] Eagle s Nest (for Salt River High School/ALA students only) SECTION 1 APPLICANT INFORMATION (PLEASE PRINT) CHILD S NAME ( Last, First and Middle) BIRTHDATE ( MM/DD/YYYY) GENDER TRIBAL AFFILIATION Male Female RACE Native American/Alaska Native Native Hawaiian or Pacific Islander White Asian Biracial/Multi-Racial Black/African American TRIBAL ENROLLMENT NUMBER ETHNICITY Hispanic-Latino Origin Non-Hispanic-Latino Origin MAILING ADDRESS CITY, STATE, ZIP CODE RESIDENTIAL DIRECTION/DESCRIPTION OF HOME Parent/Guardian s information (those with custodial/legal rights to the child only) PARENT/ GUARDIAN NAME RELATIONSHIP TO CHILD Lives with child? RACE/ETHNICITY TRIBAL AFFILIATION & ENROLLMENT NUMBER ADDRESS HOME NUMBER CELL NUMBER CITY, STATE, ZIP CODE WORK PHONE NUMBER ADDRESS (OPTIONAL) HIGHEST LEVEL OF EDUCATION COMPLETED OCCUPATION Less than HS Current HS Student /GED HS Graduate Some College Associates Bachelors Higher ATTEND SCHOOL/ TRAINING EMPLOYED FULL TIME PART TIME NO SCHOOL FULL TIME PART TIME UNEMPLOYED EMPLOYER/SCHOOL NAME EMPLOYER/SCHOOL ADDRESS (Number, Street, City, State, Zip Code) FAMILY COMPOSITION: TEEN PARENT SINGLE PARENT TWO PARENT PREGNANT Due Date: Trimester: 1 st 2 nd 3 rd Diagnosed as high risk? RELATIONSHIP STATUS: MARRIED SEPARATED DIVORCED LIVE-IN RELATIONSHIP SINGLE

4 Parent/Guardian s information (those with custodial/legal rights to the child only) PARENT/ GUARDIAN NAME RELATIONSHIP TO CHILD Lives with child? RACE/ETHNICITY Yes No TRIBAL AFFILIATION & ENROLLMENT NUMBER ADDRESS HOME NUMBER CELL NUMBER CITY, STATE, ZIP CODE WORK PHONE NUMBER ADDRESS (OPTIONAL) HIGHEST LEVEL OF EDUCATION COMPLETED Less than HS Current HS Student /GED HS Graduate Some College Associates Bachelors Higher ATTEND SCHOOL/ TRAINING FULL TIME PART TIME NO SCHOOL EMPLOYER/SCHOOL NAME OCCUPATION EMPLOYED FULL TIME PART TIME UNEMPLOYED EMPLOYER/SCHOOL ADDRESS (Number, Street, City, State, Zip Code) FAMILY COMPOSITION: TEEN PARENT SINGLE PARENT TWO PARENT RELATIONSHIP STATUS: MARRIED SEPARATED DIVORCED LIVE-IN RELATIONSHIP SINGLE List Family Members who are supported by your income: NAME AGE DOB RELATIONSHIP To Parent/Guardian Total number in family supported by the income of the parents/guardians of the child enrolling in the program and related to the parents or guardians by blood, marriage or adoption:

5 SECTION 2-ABOUT YOUR CHILD IS YOUR CHILD TRANSFERRING FROM ANOTHER HEAD START OR CHILD FIND PROGRAM? (If yes, where ) IS CHILD CURRENTLY IN FOSTER CARE? (if yes, please provide letter of placement) Case Worker s Name & Phone: DOES YOUR CHILD HAVE A DIAGNOSED DISABILITY? IF SO, IS SHE/HE ON AN IEP OR IFSP? THIS STATEMENT WILL BE USED TO DETERMINE WHETHER YOUR CHILD WILL BE ASSESSED FOR ENGLISH LANGUAGE PROFICIENCY Primary language of family at home? DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD S Speech? Not Sure Vision? Not Sure Behaviors? Not Sure Hearing? Not Sure Development? Not Sure Height/Weight? Not Sure Does your child receive early intervention services, special education, speech, physical therapy, or occupational therapy? Service Provider Name: Telephone Number: Was your child born prematurely? Yes No If yes, at how many weeks: Is your family currently receiving services from any community agency (child abuse/neglect, alcohol/substance abuse, domestic violence, homelessness, incarcerated parent, etc.) If yes, describe: Are one or both parents/guardians of child on active duty in the U.S. military? IS YOUR CHILD OR ANY FAMILY MEMBER RECEIVING? WIC SOCIAL SECURITY INSURANCE LEARN (Cash Assistance Only) FOOD STAMPS DES Child Care IS YOUR FAMILY Assistance HOMELESS? WHAT TYPE OF HEALTH INSURANCE DOES YOUR CHILD HAVE? Private Insurance AHCCCS/Medicaid KIDS CARE No Insurance WHERE DOES YOUR CHILD RECEIVE MEDICAL AND DENTAL CARE? Urgent Care/Emergency Private Doctor Private Dentist Room IHS PIMC SR Clinic None

6 SECTION 3-INCOME I RECEIVE INCOME FROM THE FOLLOWING SOURCES AT THIS TIME (CHECK ALL THAT APPLY) Wages from Employment (inc., commission, tips, bonus) Public Assistance (TANF/Cash Assistance) Scholarships or Educational Training Stipends or Grants Unemployment Compensation Child Support/Spousal Maintenance (Alimony) Income from Land or Rental Property Supplemental Security Income (SSI) or Death Benefits, annuities, retirement funds, land lease Per Capita (Non-SRPMIC) SRPMIC Per Capita: (amount will be calculated per quarterly distribution per Finance office) One household member Two household members Zero Income I currently have zero income If you have zero income, you must submit a Zero Income statement. Self-Employed If you are self-employed you must submit a notarized self-employment form. SECTION 4-DECLARATION AND CONSENT I understand that I/we have completed this application and declare that all the information provided on the ECEC application, to the best of my knowledge, is true and accurate. If any information provided on the application is found to be falsified, I/we understand that my application will not be considered for selection and will be withdrawn. PARENT/GUARDIAN SIGNATURE PRINT NAME DATE PARENT/GUARDIAN SIGNATURE PRINT NAME DATE How did you hear about ECEC?

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