STAFF ONLY Fayette County Head Start / Early Head Start STAFF ONLY Head Start/Early Head Start of Fayette County (UPDATED) - Application Full application form Staff Person Completing this application with the parent* Overview Family InformationNumber in Head Start Family *** **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.Complete for individuals identified as Head Start Family members, starting with applicant(s)Adult or Child?LastFirstDOBGenderRelationship to ApplicantComments To add additional people, click (+) below Primary Adult InformationTitle*Mr.Mrs.Ms.First Name* Middle Name Last Name* Date of Birth* Gender Male Female Email Address (account used most often) Is English Your Primary Language? Yes No If yes, what is your English level? None Little Moderate Proficient What is your primary language if English is not? What is your level of primary language? Little Moderate Proficient Relationship to child?* Foster Natural / Adopted? Grandparent Aunt / Uncle? Do you provide financial support? (Please attach documentation below if so) Provides Financial Support RaceAsianAmerican Indian OR Alaska NativeBlackWhiteOtherHispanic / LatinoNative Hawaiian / Other Pacific IslanderUnspecifiedSelect more than one if necessary If Other, Please specify Secondary Adult ** Required **Is there secondary adult information?* Yes No, not applicable TitleMr.Mrs.Ms.First Name Middle Name Last Name Date of Birth Gender Male Female Email Address (account used most often) Is English Your Primary Language? Yes No If yes, what is your English level? None Little Moderate Proficient What is your primary language if English is not? What is your level of primary language? Little Moderate Proficient Relationship to child? Foster Natural / Adopted? Grandparent Aunt / Uncle? Do you provide financial support? (Please attach documentation below if so) Provides Financial Support Check if living with this family Lives with Family RaceAsianAmerican Indian OR Alaska NativeBlackWhiteOtherHispanic / LatinoNative Hawaiian / Other Pacific IslanderUnspecifiedSelect more than one if necessary If Other, Please specify Family Contact InformationPrimary Adult Living Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Adult Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Determination of Residency* Rent / Lease Live with family or others** Own HEAD START ONLY: Is this child's physical address for classroom services the same as the primary adult's living address? Yes No If No, what is the service address? Secondary Adult Living Address (if not living with applicant) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumbersFamily Phone Number(s)Notes - Whose number is this (i.e. mom's cell, dad's work, etc.)Is this the Primary Number? Other Contacts (these are individuals not in Head Start Family)Name (first & last)Relationship to childPhone Number(s) Child's Information (first child) Head Start Early Head Start CCP New Participant Transition 3rd Year Child's First Name* Child's Middle Name Child's Last Name* Child's Gender Male Female Child's Date of Birth* RaceAsianAmerican Indian OR Alaska NativeBlackWhiteOtherHispanic / LatinoNative Hawaiian / Other Pacific IslanderUnspecifiedSelect more than one if necessary If Other, Please specify Is English the child's Primary Language? Yes No If yes, what is the child's English level? None Little Moderate Proficient What is the child's primary language if English is not? Level of child's primary language? Little Moderate Proficient Is this child related to a HS / EHS employee? Yes No If Yes, Name and relationship to the child Is this child currently participating in the following? Pre-K Counts IU / Child Alert / Early Intervention N / A Unsure Elementary School & district name which the family lives: Have you applied with HS / EHS before for this child? Yes No If yes, what year? Is there a custody agreement regarding this child? Yes No If yes, please provide / upload hereMax. file size: 50 MB.Choose any of the following concerns the parent / guardian may have with the childSpeechPhysicalHearingDevelopmentalBehavioralHealthVisionAny other concerns? ANY diagnostic documentation (IEP, IFSP, MH Evaluations) for any of the above concerns please list: Please upload a copy of any diagnostic documentation (IEP, IFSP, MH Evaluation, etc.) if providedMax. file size: 50 MB.Head Start only: If the child's application is determined to be eligible for Pre-K Counts, I give permission for this information (contact, income, birth) to be shared with PIC Pre-K Counts Project Supervisor Yes No Head Start Only: Would you be interested in home-based service for your child until a preferred classroom option becomes available? Yes No Child #2's Information Head Start Early Head Start CCP New Participant Transition 3rd Year Child's First Name Child's Middle Name Child's Last Name Child's Gender Male Female Child's Date of Birth RaceAsianAmerican Indian OR Alaska NativeBlackWhiteOtherHispanic / LatinoNative Hawaiian / Other Pacific IslanderUnspecifiedSelect more than one if necessary If Other, Please specify Is English the child's Primary Language? Yes No If yes, what is the child's English level? None Little Moderate Proficient What is the child's primary language if English is not? Level of child's primary language? Little Moderate Proficient Is this child related to a HS / EHS employee? Yes No If Yes, Name and relationship to the child Is this child currently participating in the following? Pre-K Counts IU / Child Alert / Early Intervention N / A Unsure Elementary School & district name which the family lives: Have you applied with HS / EHS before for this child? Yes No If yes, what year? Is there a custody agreement regarding this child? Yes No If yes, please provide / upload hereMax. file size: 50 MB.Choose any of the following concerns the parent / guardian may have with the childSpeechPhysicalHearingDevelopmentalBehavioralHealthVisionAny other concerns? ANY diagnostic documentation (IEP, IFSP, MH Evaluations) for any of the above concerns please list: Please upload a copy of any diagnostic documentation (IEP, IFSP, MH Evaluation, etc.) if providedMax. file size: 50 MB.Head Start only: If the child's application is determined to be eligible for Pre-K Counts, I give permission for this information (contact, income, birth) to be shared with PIC Pre-K Counts Project Supervisor? Yes No Head Start Only: Would you be interested in home-based service for your child until a preferred classroom option becomes available? Yes No Child #3's Information Head Start Early Head Start CCP New Participant Transition 3rd Year Child's First Name Child's Middle Name Child's Last Name Child's Gender Male Female Child's Date of Birth RaceAsianAmerican Indian OR Alaska NativeBlackWhiteOtherHispanic / LatinoNative Hawaiian / Other Pacific IslanderUnspecifiedSelect more than one if necessary If Other, Please specify Is English the child's Primary Language? Yes No If yes, what is the child's English level? None Little Moderate Proficient What is the child's primary language if English is not? Level of child's primary language? Little Moderate Proficient Is this child related to a HS / EHS employee? Yes No If Yes, Name and relationship to the child Is this child currently participating in the following? Pre-K Counts IU / Child Alert / Early Intervention N / A Unsure Elementary School & district name which the family lives: Have you applied with HS / EHS before for this child? Yes No If yes, what year? Is there a custody agreement regarding this child? Yes No If yes, please provide / upload hereMax. file size: 50 MB.Choose any of the following concerns the parent / guardian may have with the childSpeechPhysicalHearingDevelopmentalBehavioralHealthVisionAny other concerns? ANY diagnostic documentation (IEP, IFSP, MH Evaluations) for any of the above concerns please list: Please upload a copy of any diagnostic documentation (IEP, IFSP, MH Evaluation, etc.) if providedMax. file size: 50 MB.Head Start only: If the child's application is determined to be eligible for Pre-K Counts, I give permission for this information (contact, income, birth) to be shared with PIC Pre-K Counts Project Supervisor? Yes No Head Start Only: Would you be interested in home-based service for your child until a preferred classroom option becomes available? Yes No Childcare ServicesHave you been determined eligible and on a waitlist for ELRC subsidized funds? Yes No Are you receiving Early Learning Resource Center (ELRC) subsidized funds? Yes No Is your child receiving child care services (either in a daycare or a relative)? Yes No If yes, what is the name of the child care facility or Person? Phone Number of facility or person above? County of facility or person above is located? May Head Start, the Child Care listed above and ELRC share written information and have verbal communication regarding the Head Start/Early Head Start, Child Care and ELRC services? Yes No Please list children that the above childcare questions applies to Transportation(complete this section for HS children ONLY)Are you able to transport to and from a Head Start center on a daily basis, if ‘yes’, your child may be placed on a priority list for a ‘parent transport only’ classroom: Yes No If Yes, please choose all Head Start Centers you will transport to and from daily below:ConnellsvilleConnellsville Twp.Lemont FurnaceMasontownMenallenMill RunMt. VernonRedstoneRt. 119Rt. 857Washington Twp.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. If transportation is not available to your home or in walking distance from your home, are you able to transport to a central stop (up to 5 miles) 5 days/week: Yes No I understand if I checked ‘No’ above, that I cannot meet the school bus, that other, more suitable placement for my child will be offered. Yes, I understand Risk AssessmentRisk assessment to identify a child’s need for services. Any out of ordinary situations, see ERSEA SupervisorPlease choose all that applyParent and/or legal guardian who currently or previously uses and/or in substance abuse treatment/counselingSingle female headed householdReferred to/participating in services by a child welfare agency (CYS) (MUST HAVE DOCUMENTATION)eChild in care of non-biological parentCurrently Incarcerated Parent and/or legal guardian as a parent to child applyingSingle male headed householdParental Education: No high school diploma or GEDChild was in another HS/EHS program during current PY (Other than Fayette County)Child has suspected disabilityChild's name for what is selected above: Please choose all that applyParent and/or legal guardian who currently or previously uses and/or in substance abuse treatment/counselingSingle female headed householdReferred to/participating in services by a child welfare agency (CYS) (MUST HAVE DOCUMENTATION)eChild in care of non-biological parentCurrently Incarcerated Parent and/or legal guardian as a parent to child applyingSingle male headed householdParental Education: No high school diploma or GEDChild was in another HS/EHS program during current PY (Other than Fayette County)Child has suspected disabilityChild's name for what is selected above: Please choose all that applyParent and/or legal guardian who currently or previously uses and/or in substance abuse treatment/counselingSingle female headed householdReferred to/participating in services by a child welfare agency (CYS) (MUST HAVE DOCUMENTATION)eChild in care of non-biological parentCurrently Incarcerated Parent and/or legal guardian as a parent to child applyingSingle male headed householdParental Education: No high school diploma or GEDChild was in another HS/EHS program during current PY (Other than Fayette County)Child has suspected disabilityChild's name for what is selected above: CYS Documentation file uploadMax. file size: 50 MB.Family Income Information Used to Determine EligibilityIncome/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?Income Notes (if per diem, shift pay, overtime, how long at job, must gather more information):Certification*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. I agree to the above Certification Statement Internal Family Income Checklist – NOT USED TO DETERMINE ELIGIBILITYCheck the documentation collected & attached:Please upload all income and birth verification documents here Drop files here or Select files Max. file size: 50 MB. Income Tax Form 1040 W-2 Pay Stub or Pay Envelopes Bank Statements Unemployment Social Security Benefit (other than SSI): Survivor Benefit Disability Residency Questionnaire Self-Declaration of Income Worksheet Written Statements from employers Foster care reimbursement TANF documentation SSI documentation Child Support Letter Any Other documentation? Please Explain: Verification of No Income Form NOTES TO ERSEA STAFF ONLY Early Head Start of Fayette County - Pregnant Woman Application Full application form Staff Person Completing this application with the parent* Overview Family InformationNumber in Head Start Family *** **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. ***Pregnant woman is counted as 2 members of the HS family.When is the pregnant woman's due date? Check if pregnant woman is expecting twins or more Expecting twins Expecting triplets Complete for individuals identified as Head Start Family members, starting with applicant(s)Adult or Child?LastFirstDOBGenderRelationship to ApplicantComments To add additional people, click (+) below Primary Adult InformationTitle*Mr.Mrs.Ms.First Name* Middle Name Last Name* Date of Birth* Email Address (account used most often) Is English Your Primary Language? Yes No If yes, what is your English level? None Little Moderate Proficient What is your primary language if English is not? What is your level of primary language? Little Moderate Proficient Do you provide financial support? (Please attach documentation below if so) Provides Financial Support RaceAsianAmerican Indian OR Alaska NativeBlackWhiteOtherHispanic / LatinoNative Hawaiian / Other Pacific IslanderUnspecifiedSelect more than one if necessary If Other, Please specify Secondary Adult ** Required **Is there secondary adult information?* Yes No, not applicable TitleMr.Mrs.Ms.First Name Middle Name Last Name Date of Birth Gender Male Female Email Address (account used most often) Is English Your Primary Language? Yes No If yes, what is your English level? None Little Moderate Proficient What is your primary language if English is not? What is your level of primary language? Little Moderate Proficient Relationship to pregnant woman? Husband Boyfriend Grandparent Parent Do you provide financial support? (Please attach documentation below if so) Provides Financial Support Check if living with this family Lives with Family RaceAsianAmerican Indian OR Alaska NativeBlackWhiteOtherHispanic / LatinoNative Hawaiian / Other Pacific IslanderUnspecifiedSelect more than one if necessary If Other, Please specify Family Contact InformationPrimary Adult Living Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Adult Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Determination of Residency* Rent / Lease Live with family or others** Own Secondary Adult Living Address (if not living with applicant) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumbersFamily Phone Number(s)Notes - Whose number is this (i.e. mom's cell, dad's work, etc.)Is this the Primary Number? Other Contacts (these are individuals not in Head Start Family)Name (first & last)Relationship to childPhone Number(s) Risk AssessmentRisk assessment to identify a child’s need for services. Any out of ordinary situations, see ERSEA SupervisorPlease choose all that applyParent and/or legal guardian who currently or previously uses and/or in substance abuse treatment/counselingSingle female headed householdReferred to/participating in services by a child welfare agency (CYS) (MUST HAVE DOCUMENTATION)eChild in care of non-biological parentCurrently Incarcerated Parent and/or legal guardian as a parent to child applyingSingle male headed householdParental Education: No high school diploma or GEDChild was in another HS/EHS program during current PY (Other than Fayette County)Child has suspected disabilityFamily Income Information Used to Determine EligibilityIncome/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?Income Notes (if per diem, shift pay, overtime, how long at job, must gather more information):Certification*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. I agree to the above Certification Statement Internal Family Income Checklist – NOT USED TO DETERMINE ELIGIBILITYCheck the documentation collected & attached:Please upload all income and birth verification documents here Drop files here or Select files Max. file size: 50 MB. Income Tax Form 1040 W-2 Pay Stub or Pay Envelopes Bank Statements Unemployment Social Security Benefit (other than SSI): Survivor Benefit Disability Residency Questionnaire Self-Declaration of Income Worksheet Written Statements from employers Foster care reimbursement TANF documentation SSI documentation Child Support Letter Any Other documentation? Please Explain: Verification of No Income Form NOTES TO ERSEA
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