2007 Income Guidelines

Transcription

1 Bismarck Early hood Education Program (701) Fax: (701) MIKE AHMANN EXECUTIVE DIRECTOR MICHELLE DZURA-HOUGEN BECEP-COORDINATOR LAUREL NYBO HEAD START-COORDINATOR School Year Dear Parent/Guardian, Thank you for showing an interest in Head Start. Please complete and return the attached Head Start Application. Ninety percent of the families who enroll in Head Start fall within the following income guidelines and 10% of the families are over the income guidelines. All TANF and children s families who receive Foster Care payments are eligible regardless of family income. ren with disabilities are encouraged to apply Income Guidelines Number of People Annual Gross Income In Family 1 $10,210 2 $13,690 3 $17,170 4 $20,650 5 $24,130 6 $27,610 7 $31,090 8 $34,570 Applications cannot be processed until the following paperwork is complete and returned to BECEP at Richholt: Verification of your income (income tax statement, pay stubs, or TANF statement or foster care payment) Proof of legal guardianship or custody documentation s official birth certificate Application (All questions complete and signed) After receiving your application, we will notify you as to the status of your child s application. The following information is required by Head Start: Insurance information (Medicaid, private insurance or CHIP) A current dental exam (form is enclosed to take to provider) A current physical exam from Health Tracks, Bismarck/Burleigh Nursing, Indian Health Services, or your family physician (form is enclosed to take to provider) A current hemoglobin and blood lead screening An up-to-date immunization record Please contact the Head Start office if you have any questions or need assistance completing the application. Please return applications to: Sincerely, Richholt 720 North 14 th Street Bismarck, ND Deb Selzler Enrollment Manager Mailing Address: Location: 806 North Washington Street 720 North 14 th Street Bismarck, ND Bismarck, ND 58501

2 HEAD START FAMILY DEMOGRAPHICS FORM SECTION1: ELIGIBLE CHILD Complete this section for each child in the family eligible to receive direct services through Head Start. The child must be 3 years old by August 31 of the current year. First Name, MI, Last Name Preferred/Nickname Date of Birth Head Start Eligible Social Security # Gender Male Female Male Female Street City, State Zip Code Telephone Number Head Start Eligible Mark all that apply Living Mailing Other Living Mailing Other What race/ethnicity does this person consider herself/himself to be? American Indian or Alaskan Native Black or African American Hispanic or Latino American Indian or Alaskan Native Black or African American Hispanic or Latino Specify Specify Language Spoken: English Other: Specify English Other: Specify English Speaking Ability: Very Well Well Not Well None Very Well Well Not Well None Concerns about child s: Speech Language Behavior Learning Health No (skip to next question) Don t know (skip to next question) Describe Concerns: No (skip to next question) Don t know (skip to next question) Describe Concerns: previously enrolled in Head Start or other childhood development Is the child to be cared for by someone other than the primary supporting adult in addition to participating in Head Start? Concerns expressed by: Primary Care Provider Medical Provider Family Member Social Service Agency Other Person/Agency: No (skip to next question) Head Start Center-based for 3-5 yr Day Care Provider(s) (Mark all that apply) Older sibling under age 12 Older sibling age 12 or older Relative Adult non-relative in child s own home Adult non-relative in non-relative s home Care Center Specify Not yet arranged Concerns expressed by: Primary Care Provider Medical Provider Family Member Social Service Agency Other Person/Agency: No (skip to next question) Head Start Center-based for 3-5 yr Day Care Provider(s) (Mark all that apply) Older sibling under age 12 Older sibling age 12 or older Relative Adult nonrelative in child s own home Adult nonrelative in non-relative s home Care Center Specify Not yet arranged

3 Complete this section for all family members not included in Section 1. List the Financial Head of Household first. Person is a Supporting Adult in the (ren) s Life: What race/ethnicity does this person consider herself/himself to be? Parent/Guardian Person is Financial Head of Household of this family: Person is receiver of correspondence: American Indian or Alaskan Native Black or African American Hispanic or Latino Specify Parent/Guardian Person is receiver of correspondence: Person resides with the Financial Head of Household: Sometimes American Indian or Alaskan Native Black or African American Hispanic or Latino Specify Person is currently pregnant: Not Applicable Not Applicable Person s relationship to the Eligible Biological Parent Aunt or Uncle Biological Parent Aunt or Uncle (ren) listed in Foster Parent Sibling Foster Parent Sibling Section 1: Adoptive Parent Step Sibling Adoptive Parent Step Sibling Step-Parent Legal Guardian Step-Parent Legal Guardian What is this person s current occupational status? Today s Date / / What is this person s highest level of education completed? Attended vocational training, trade or business school: Participated in Government Training Program Person is willing to pursue additional education/job training: Start or other childhood development Grandparent No biological/legal relationship Paying Job Unemployed Full-time (34hrs+/wk) With past Part-time employment experience Seasonal-Non Agricultural With no previous Seasonal-Agricultural job experience Employed and in School In School Other Toward high school diploma/ged Homemaker Toward trade/business qualification Retired Toward College Degree Unable to work Toward postgraduate degree due to disability In school and employed Not applicable Other In job training program Training program Training program with salary without salary No (skip to next question) Did you receive a certificate/license? Yes No (skip to next question) Training program(s) attended (mark all that apply) JOBS JTPA Job Corps Head Start Specify Complete this section for all family members not included in Section 1. Grandparent No biological/legal relationship Paying Job Unemployed Full-time (34hrs+/wk) With past Part-time employment experience Seasonal-Non Agricultural With no previous Seasonal-Agricultural job experience Employed and in School In School Other Toward high school diploma/ged Homemaker Toward trade/business qualification Retired Toward College Degree Unable to work Toward postgraduate degree due to disability In school and employed Not applicable Other In job training program Training program Training program with salary without salary No (skip to next question) Did you receive a certificate/license? Yes No (skip to next question) Training program(s) attended (mark all that apply) JOBS JTPA Job Corps Head Start Specify

4 What race/ethnicity does this person American Indian or Alaskan Native American Indian or Alaskan Native consider herself/himself to be? Black or African American Hispanic or Latino Black or African American Hispanic or Latino Specify Specify Person s relationship to the Eligible Sibling Step Sibling Sibling Step Sibling (ren) listed in Section 1: What is this person s highest level of education completed? Start or other childhood development (End of section) Head Start Center-based for 3-5 yr Head Start Center-based for 3-5 yr What race/ethnicity does this person American Indian or Alaskan Native American Indian or Alaskan Native consider herself/himself to be? Black or African American Hispanic or Latino Black or African American Hispanic or Latino Specify Specify Person s relationship to the Eligible Sibling Step Sibling Sibling Step Sibling (ren) listed in Section 1: What is this person s highest level of education completed? Start or other childhood development Head Start Center-based for 3-5 yr Head Start Center-based for 3-5 yr

5 Complete this section for all family members not included in Section 1. What race/ethnicity does this person American Indian or Alaskan Native American Indian or Alaskan Native consider herself/himself to be? Black or African American Hispanic or Latino Black or African American Hispanic or Latino Specify Specify Person s relationship to the Eligible Sibling Step Sibling Sibling Step Sibling (ren) listed in Section 1: What is this person s highest level of Less than/equal to 4 education completed? grade graduate/ged Start or other childhood development (End of section) Head Start Center-based for 3-5 yr Head Start Center-based for 3-5 yr What race/ethnicity does this person American Indian or Alaskan Native American Indian or Alaskan Native consider herself/himself to be? Black or African American Hispanic or Latino Black or African American Hispanic or Latino Specify Specify Person s relationship to the Eligible Sibling Step Sibling Sibling Step Sibling (ren) listed in Section 1: What is this person s highest level of education completed? Start or other childhood development Head Start Center-based for 3-5 yr Head Start Center-based for 3-5 yr

6 Head Start Family Demographics Forms SECTION 3: FAMILY COMPOSITION AND RESOURCES Family Type: Two parent family Two parent family (biological parent and step parent) Single parent family (mother figure only) Single parent family (father figure only) Single parent family (mother figure only) living with partner Single parent family (father figure only) living with partner Other relative(s) Foster family Grandparent Other family type Family Income: Number of Adults in Family Number of ren in Family Number of Adults contributing to the Income For Office Use Only: Income Submitted: 1040 Tax Statement Pay Stubs Unemployment Foster Care Receiving Support W2 Statement Public Assistance Form (TANF) Care Assistance Supplemental Security Income (SSI) Specify Annual Income $ Time period income based on: Previous Month Last Calendar Year Income Eligible: Yes/No Types of Services or Financial Assistance Received (mark all that apply): No services received Medical financial assistance (i.e. Medicaid/Medicare) Unemployment insurance Food Stamps Public housing assistance Public Assistance/Welfare (TANF) Energy program assistance WIC EPSDT/Health Tracks Circle: Supplemental Security Income (SSI) Foster care/adoption subsidy Subsidized Care Specify support/alimony-paying/receiving Is a Recipient of Supplemental Security Income (SSI): No Housing Payment Arrangement: Own housing Exchange services for housing Receive subsidized housing Rent housing Make no payment for housing Specify Type of Housing: House Mobile home/trailer Homeless/no housing Migrant Housing Apartment Community shelter Hotel/motel room

7 Length of Time at Current Address: Less than 6 months 6-12 months 1-2 years More than 2 years Number of Times Family Moved in the Past 12 Months: Family has not moved Once Twice Three times Four or more times Homeless in Past 12 Months (including currently homeless): No (skip to next question) Length of time homeless: Less than 1 month 1-3 months 3-6 months More than 6 months Family Currently Has Means of Transportation: Yes No Primary mode(s) of transportation used (mark all that apply): Private vehicle (car, truck, van) Public transportation (Transit or taxi) Friend s or relative s vehicle Family has alternate means of transportation if primary mode(s) are unavailable: Yes No Alternative means of transportation (mark all that apply): Private vehicle (car, truck, van) Public transportation (Transit or taxi) Friend s or relative s vehicle Transportation is Provided to Eligible Families Within Designated Areas. Alternative Telephone Numbers the Eligible Family can be Contacted: Home: Cellular: Work: Other: I am the Legal Parent/Guardian of the Applicant(s). Yes No I Certify That the Information Provided in this Form is Accurate and Truthful to the Best of my Knowledge. Parent/Guardian Signature: Date: / / Staff Signature: Date: / / Office Use Only: Date Received: / / Date of Verification: / / Enrollment Date: / / The Bismarck Public School District does not discriminate on the basis of race, sex, color, national origin, religion, age or disability in admission or access to, or treatment or employment in, its programs and activities. For more information, call For the hearing impaired, call the TDD Relay Service,

8 Head Start Physical Exam Date Completed: / / Physical Exam/Assessment: Name: DOB: / / Normal Abnormal Referred Not Evaluated Height Weight General Appearance Posture, Gait Speech Head Skin Eyes External Aspects Optic Fundoscopic Cover Test Ears External Canal Nose, Mouth, Pharynx Teeth Heart Lungs Abdomen (Include Hernia) Genitalia Bones, Joint, Muscles Neurological/Social Gross Motor Fine Motor Communication Skills Cognitive Self-Help Skills Social Skills Glands (Lymphatic/Thyroid) Muscular Coordination Hearing Testing Urine Test Hgb Results Hgb Deferred Vision Lead Screening Other Needs Treatment: Yes No Medical Provider Signature: **Hemoglobin is a requirement of the Head Start Standards

9 Oral Health Assessment Date Completed: / / Name: Provider Setting: Home Doctor/Clinic School/Center Employment Other: Specify Assessment Type: Screening Assessment Oral Condition: Number of Times Per Day Brushes Teeth: Gum Condition: Normal Swollen Bleeds Easily Infected Dental Needs: No Needs Treatment Cleaning Fluoride Supplement Oral Hygiene Instruction Other: Specify Provider Signature: Date: Date dental work completed: / /