NeighborImpact Head Start Application

Transcription

1 NeighborImpact Head Start Application What does NeighborImpact Head Start have to offer you and your family? Free preschool and family support for children ages 3 and 4 from low-income families 128 days of preschool services for 3 hours 45 minutes, 4 days a week for children in Crook and Deschutes counties Services for children of all abilities including children with disabilities Enrollment for children and families with the greatest need for Head Start services Please fill in the application form completely and accurately. The information you provide will help us determine your child s eligibility for Head Start and help us prioritize your application. All shared information will be held in strict confidence. If you are uncomfortable completing any part of this application, have questions about your eligibility, or would like to discuss your situation with a staff member, please contact Garth Brown, Head Start Technician, at , or garthb@neighborimpact.org To qualify for services your child must be 3 or 4 years old on or before September 1 st of the year you are applying. I have signed/dated the application. I have provided eligibility documentation o Proof of Receipt of TANF cash assistance or SSI o Foster Placement Form o Income documentation Questions? Please call or NeighborImpact Head Start 2303 SW First St. Redmond, OR (Fax)

2 I was referred to Head Start by: Head Start Application Please fill in the form completely and accurately. If you have questions please call Garth Brown, Head Start Technician, at or Child Information Child/Applicant Name: Child s Birthdate: Child s Age: Male Female What is your child s primary language? How well does your child speak this language? Very Well Well Not Well Not at all Does your child speak another language? If so, what language? How well does your child speak this language? Very Well Well Not Well My child has a diagnosed chronic health condition or life threatening illness. Please Explain: My child has a diagnosed disability, including mental health. Please Explain: My child has a disability, is receiving services through ECSE (Early Childhood Special Education) or EI (Early Intervention), and currently has an Individualized Family Service Plan (IFSP)? Yes No In order to serve my child better, I give NeighborImpact Head Start permission to contact EI/ECSE to verify service. Signature: Is this child in foster care? Yes No If yes, what is the name of the child s caseworker? Caseworker phone number: Caseworker Has this child ever been in foster care? Yes No Please select the type of family that best describes that of the child applying to this program. Single Parent Two Parent ( married biological acting step parent joint custody) Foster Parent Single Parent living with other adults Not the Child s Parent Other: Parent/Guardian Information (The person signing the application should complete this section.) Parent/Guardian s Name: Living Address: County Mailing Address (if different): Telephone: (Primary) (Secondary) (Work) (Message) E mail address: What is your primary language? How well do you speak this language? Very Well Well Not Well Not at all Do you speak another language? If so, what language? How well do you speak this language? Very Well Well Not Well Do you have full custody joint custody no custody over this child? Check only one.

3 Parent/Guardian Information continued Second Parent/Guardian s Name: Living Address: Mailing Address (if different): Telephone: (Primary) (Secondary) (Work) (Message) E mail address: What is your primary language? How well do you speak this language? Very Well Well Not Well Not at all Do you speak another language? If so, what language? How well do you speak this language? Very Well Well Not Well Do you have full custody joint custody no custody over this child? (Check only one) Family Information Head Start must know how many people are living in your household and the total family income in order to determine if your family income is at or below the Federal poverty guidelines. Family is defined for our purposes as all persons living in the same household who are supported by the income of the parent(s) or guardian(s) of the enrolling child and are related to the parent(s) or guardian(s) by blood, marriage, or adoption. Please list everyone living in the home, including the applying child. Name (First, Middle, Last) Date of Birth (Required) Relationship to Child Level of Education (i.e. grade level, GED, Diploma) Attach additional page if necessary. Need Factors (The following will help prioritize your placement on the waiting list. Please check all that apply.) Indicate any issues which have occurred to your child s immediate family. Child abuse or neglect (open case with child welfare) Death/Loss of parent or primary caregiver Divorce or separated (within the last 24 months) Domestic Violence (within the last 24 months) Homelessness* Parent currently incarcerated Substance abuse of adult family member Child was affected by drugs or alcohol at birth Sibling with a diagnosed disability Race Ethnicity Non Non Non Non Non Parent/guardian has chronic or life threatening illness or physical disability that limits ability to care for child Parent/guardian has diagnosed mental health condition Parent/guardian has developmental or cognitive or intellectual disability Parent/guardian has difficulty reading, writing, or understanding written words Military deployment Other: *Homelessness is defined as lacking a fixed, regular and adequate night time residence; or living temporarily in shelters, hotels, or vehicles; or moving frequently between the home of relatives and friends.

4 Does your child have any diagnosed food allergies? Yes No If yes, please explain: Does your child require any medications during the school day? Yes No If yes, please explain Income* (Eligibility is based upon income within the Federal Poverty Guidelines. Proof of income is REQUIRED and must include the total income of all members of the family listed above.) Income verification can be from the previous calendar year or from the last 12 months. If you have questions regarding verification of income, or if you are unable to provide income documentation, please contact Garth Brown, Head Start Technician, at Your application is not complete without proper income verification documentation. Do you currently receive TANF? (Please attach proof of TANF from DHS.) Yes No (Includes on going TANF cash grant. Does not include Food Stamps, OHP Medical Card, Child Care or Emergency Assistance.) Do you or anyone in your family currently receive Supplemental Security Income (SSI)? Yes No Is this application for a foster child placed with you through the State of Oregon? Yes No Answer the following questions based on income received either the previous calendar year or the last 12 months. Are you/were you employed? Yes No Have you received unemployment benefits? Yes No Have you received child support? Yes No Have you received grants/scholarships/stipends? Yes No Types of Income or Financial Assistance Received last 12 months or calendar year (Please mark all that apply.) Employment income from wages, salary, cash payments, or net income from self employment Child support or alimony College or university scholarships, grants, fellowships, and internships, or training stipends Unemployment insurance benefits, strike benefits, worker s compensation benefits, veteran s benefits Pensions, regular insurance or annuity payments, military retirement pay Regular payments for Social Security or Social Security Death or Disability payments (SSDI) Periodic receipts from estates or trusts, net rental property income TANF benefits Attach any of the following documents for income verification for the previous calendar year or the last 12 months as required, whichever most accurately reflects your family s current situation. Your application is not complete without the inclusion of income verifying documents related to your answers above. Income Tax Form (Federal 1040) W 2 Forms Employer Statement/Paystub Unemployment Printout Child Support Information Social Security Benefits Foster Placement Form SSI Award Letter Student/Financial Aid/Award Letter (by term) Adoption Stipend TANF Statement *HEAD START PROGRAM DEFINITION OF INCOME: Income means total cash receipts before taxes from all sources, with certain exceptions. Income includes: (1) money, wages or salary before deduction; (2) net income from non farm or farm self employment; (3) social security or railroad retirement; (4) unemployment compensation, strike benefits, workers compensations, veteran s benefits, or public assistance; (5) training stipends; (6) alimony, child support, military family allotments, other regular support from absent family member or someone not living in the household; (7) private pensions, government pensions including military retirement, insurance or annuity payments; (8) college scholarships, grants, fellowships, assistantships; (9) dividends, interest, net rental income, net royalties, receipts from estates or trusts; (10) net gambling or lottery winnings.

5 Transportation (Head Start has limited transportation to and from school. Some families may live outside of our bus routes or live in areas designated as Self transport REQUIRING families to transport their child to and from school.) If my child is on a transportation route, I give permission for Head Start to transport my child to and from school. Please list your child s pick up and drop off address. (One address please) Street address Apt. # City This address is: Home Child Care Other: Parent/Guardian Authorizations I certify the information provided in this application is accurate and truthful to the best of my knowledge, and authorize Head Start to verify information as needed. Inaccurate, untruthful, or fraudulent information could result in my child s disenrollment from NeighborImpact s Head Start program, and may result in serious legal consequences for me. The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint form, found online at or at any USDA office, or call (868) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). USDA is an equal opportunity provider and employer. NeighborImpact does not discriminate against any person on the basis of race, color, national origin, disability or age of admission, or participation in its programs, services and activities, or in employment. For further information about this policy, or to arrange for an accommodation, contact Human Resources/Section 504 Coordinator, phone number (541) Ext. 115, State Relay 711. This project is financed in part with 33%, or $1,404,470 of federal funds, and receives less than 1% of funding in nongovernmental sources.