STAFF ONLY Beaver County Head Start / Early Head Start

STAFF ONLY Head Start/Early Head Start of Beaver County - Application

Full application form
  • Overview Family Information

  • **Definition of: Head Start Family Member means all persons living in the same household who are: Supported by the income of the parent(s) or guardian(s) of the child enrolling or participating in the program, AND related to the parent(s) or guardian(s) by blood, marriage, or adoption; OR the child’s authorized caregiver or legally responsible party.
  • Adult or Child?LastFirstDOBGenderRelationship to ApplicantComments 
    To add additional people, click (+) below
  • Primary Adult Information

  • Select more than one if necessary
  • Secondary Adult ** Required **

  • Select more than one if necessary
  • Family Contact Information

  • Family Phone Number(s)Notes - Whose number is this (i.e. mom's cell, dad's work, etc.)Is this the Primary Number? 
  • Name (first & last)Relationship to childPhone Number(s) 
  • Child's Information (first child)

  • Select more than one if necessary
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • Child #2's Information

  • Select more than one if necessary
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • Child #3's Information

  • Select more than one if necessary
  • Max. file size: 50 MB.
  • Max. file size: 50 MB.
  • Childcare Services

  • Transportation

    (complete this section for HS children ONLY)
  • Transportation services are not guaranteed. Per the Transportation Policy, bus stop locations may be predetermined ‘centralized’ bus stops. NOTE: Due to a limited fleet of buses, it may be necessary for your family to meet the school bus for your child to be in a classroom.
  • Risk Assessment

    Risk assessment to identify a child’s need for services. Any out of ordinary situations, see ERSEA Supervisor
  • Max. file size: 50 MB.
  • Family Income Information Used to Determine Eligibility

    Income/Eligibility Information for Relevant Time Period (1) The 12 months preceding the month in which the application is submitted; or (2) During the calendar year preceding the calendar year in which the application is submitted, whichever more accurately reflects the needs of the family at the time of application.): Reminder: For each income source discussed, you MUST indicate month/year they started receiving the income and when it ended. If they are still receiving the income, put the month/year it began to present. Example: Sally began working at Walmart in January 2016 – March 2018. She then started working at Costco from April 2018-present. NOTE: if they are not reporting income for the entire Relevant Time Period, then ask if they worked prior and indicate in the notes below. Questions to keep in mind: Where did you work? How long did you work there? If not for a year, where before? How often were you paid?
  • I certify that all this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours. This information is confidential and will be handled accordingly; however If Head Start receives information that a client may have committed fraud or otherwise violated any criminal or civil statute or regulation, I AGREE THAT the program may relay those facts to the appropriate agency.
  • Internal Family Income Checklist – NOT USED TO DETERMINE ELIGIBILITY

    Check the documentation collected & attached:
  • Drop files here or
    Max. file size: 50 MB.