Yes. Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): _

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1 Page 1 ~ Martin County Community Action, Inc. Head Start Program P.O. Box 806/415 E. Blvd. Suite 130 Williamston, NC (252) Fax: (252) DPlease bring proof of income, child's birth certificate, shot record, social security card, and medicaid card. Child's Application Parent Name: Child's Name: (First) (Last) (Middle) Date of Birth: SSN: Gender: Male Female Race: Black White Hispanic or Latino Other: (Please Indicate: Language Spoken at Home: Primary: How well does your child speak English: Very Well Concerns about your child's overall health and development: Describe concerns: Secondary: Date: Well Not Well Not at all Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): Child is cared for by someone other than the parent: Sibling under 12 Adult non-relative-not in home Adult non-relative in home Yes No Sibling over 12 Other (Please Specify: Relative Child Care Center Not yet arranged Mailing Address: -::-- --:::-:----:-:: : Street City/State Zip code Living Address: Street City/State Zip code Home Phone: Cell Phone Number: Is your child enrolled in another child care setting? Yes No If yes, name of program: FOR AGENCY USE ONLY Program Applying For: Program Type: Status: Status Date: Center: Class: Start Date: Income Eligibility Date:

2 Name of Primary Parent/Guardian: Relationship to Child: Page 2 Person's role in the household: Mother/Mother Figure Father/Father Figure Legal Guardian Other (Please Indicate): Date of Birth: SSN: Gender: Male Female Marital Status: Single Married Separated Divorced Widowed Race: Black White Hispanic or Latino Asian Other(Please Specify: Language Spoken in Home: Primary: Secondary: How well does this person speak? English: Very Well Is this biological parent under age 17? Yes No Parent willing to pursue additional Education/Job Mailing Address: Home Phone: Occupation Status: Paying Job: Full Time (Over 30 hours a week) Part Time Seasonal- Agricultural Seasonal- Non-Agricultural Training? Work Phone: Well Yes No Not Well Unemployed: Homemaker Retired Disabled Lost job Cell Phone: Not at all Job Training Program: Yes No In School: In school and employed High SchoollGED College Degree Graduate Degree Other (Please Specify) In SchoollPart Time In school and employed High SchoollGED College Degree Graduate Degree Other (Please Specify) Highest Level of Education: less than 8 th grade 9 th -1 i h grade lih grade (no diploma) no school completed High School Grad GED Some College (no degree) Certificate (college trade) Associates Degree Bachelor's Degree Master's Degree Doctorate Degree Name of other Parent/Guardian living in the home (if applicable) Relationship to Child: Date of Birth: SSN: Gender: Male Female Marital Status: Single Married Separated Divorced Widowed Race: Black White Hispanic or Latino Asian Other(Please Specify: Language Spoken in Home: Primary: Secondary: How well does this person speak? English: Very Well Well Not Well Not at all Is this biological parent under age 17? Yes No Parent willing to pursue additional Education/Job Training? Yes No Mailing Address:

3 Home Phone: Occupation Status: Paying Job: Full Time (Over 30 hours a week) Part Time Seasonal - Agricultural Seasonal- Non-Agricultural In School: In school and employed High SchoollGED College Degree Graduate Degree Other (Please Specify) Work Phone: Unemployed: Homemaker Retired Disabled Lost job In School/Part Time In school and employed High SchooIlGED College Degree Graduate Degree Other (Please Specify) Cell Phone: Job Training Program: Yes No Page 3 Highest Level of Education: less than 8 th grade 9 th -12th (Trade - I:> lih grade (no diploma) no school completed High School Grad GED Some College (no degree) Certificate (college trade) Associates Degree Bachelor's Degree Master's Degree Doctorate Degree Family Type: (check one only) Two parent Family Foster Family Single Parent (Mother Only) Single (Living with Partner) Single Parent (Father Only) Other Relatives Other Family Type: (Please Specify) Housing (check one only) House Apartment Mobile Home/Trailer HotellMotel Community Shelter Migrant Housing Homeless Other: Housing Payment: Rent Own Section VIII (check one only) Make no payment Public Housing Other (please specify) Services or financial Assistance received: (please check all apply) No services received Start Date: End Date Medical Assistance Child Support! Alimony Energy Assistance Food Stamps Foster Care/Adoption Public Assistance (WFF A, TANF) Public Housing SSI/SS Unemployment Insurance WIC

4 Page 4 Length of time at current address: less than 6 months 6-12 months 1-2 years more than 2 years Number of moves in past 12 months Homeless in past 12 months Yes No Length of time homeless: (months) Transportation: Family has means of transportation? Yes No Alternate means of transportation? Yes No Check first box for primary and second box for alternate means of transportation: Private Vehicle (car, truck, van) Public Transportation (taxi, bus, transit, city bus) Relative/Friend's vehicle School Bus Other (please specify) Family Referred from: Comments: Please list all other children living in the household under 18: Name Age Date of Birth Social Security # Relationship to Child Please list all other adults living in the household: Name Relationship to Child Current Insurance Type: Medicaid ID# NC Health Choice ID# Private Insurance (Please complete below) No Insurance Insurance Provider Name: Policy Number:

5 Page 5 Effective Date: Expiration Date: Primary Insurance? Yes No Has Dental Coverage Yes No Current Medical Provider: Phone Number #: Date of last physical: Current Dental Provider: Phone Number: #: Date of last Exam: Does your child receive any specialized services or is suspected of needing services such as speech,llanguage, physical or occupational therapy. If yes, please check the appropriate Disability Evaluated by Suspected Identified Date YeslNolNA YeslNolNA Autism EmotionallBehavioral Disorder Health Impairmentlincl uding deafness Learning Disability Mental Retardation Multiple Disabilities Non-categorical/developmental delay Orthopedic Impairment Speech/Language Traumatic brain injury impairment Visual Impairment, including blindness Other: MCCA, Inc Head Start Program supports the Office of Head Start Fatherhood Initiative Program and your assistance is needed in getting your child's father/or positive male role model in their health and child development. If the father lives outside the home, please provide the following information in order that we may contact him: Name: Address: Telephone: Alternate Phone Number: I certify that the information provided on this application is accurate and truthful to the best of my knowledge and is subject to verification. I am aware that I may be subject to termination from the program for false information. Parent Guardian Printed Name: Parent/Guardian Signature: Date:

6 Page 6 Application submitted during the period of January through March for next school year will receive a letter indicating the child status by April 30 th Applications submitted any other time during the year will receive notification within 30 days. FOR AGENCY USE ONLY Application Date: Categorically Eligible: Child's Age: Income Eligible: Over Income Guidelines: Income: Diagnosed Disability: Suspected Disability (physical) Income Verification: Individual Tax Form 1040 Public Assistance (TANF/WFFA) Letter Foster Care Homeless W-2 Form Year --- Pay Stub Work History-Verification of Employment SSIISS (Letter) Birth Certificate Other (please specify): Written Employer Statement Application Taken by: Staff name/position Date: Print Case Manager Name: Case Manager Verification Signature: Date: Comments:

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