Head Start Enrollment Application · CSA Head Start Enrollment Application. Revised 08/26/2014 ... Adult's Information - Part 1 These questions are for the OTHER parent/guardian LIVING

CSA Head Start Enrollment Application Revised 08/26/2014 ENGLISH**YOUR REQUEST CANNOT BE PROCESSED IF ANY FIELDS ON THIS APPLICATION ARE BLANK.**

Did this person file last year's 1040 U S Individual Income Taxes? (select one)

PRIMARY Adult's Information - Part 1 These questions are for the parent/guardian LIVING IN THE HOME who

is the HEAD OF HOUSHOLD.First Name MI Last Name

Birth Date (mmddyyyy)

Disabled (select one)

Yes No

Veteran (select one)

Yes No

In the Military (select one)

Yes No

Marital Status ((select one)

Married Legally Separated Single Divorced Widowed

Gender (select one)

Male Female

Ethnicity (select one)

Hispanic Non-Hispanic

Race (select one)

American Indian/Alaskan Native Asian Black/African American

Native Hawaiian/Other Pacific Islander White Unspecified

Other:

Primary Language (select one)

English Spanish Other

English-Speaking Ability (select one)

None Poor Well Very Well

Medical Insurance Coverage (mark all that apply)

None Medicaid Nevada Check Up Indian Health Services(IHS)

Private Medicare VA/Tricare Other

Highest Level of Education (select one)

Grade 9 or Less High School Non-Graduate High School Diploma

GED Some College Associate's Degree Bachelor's Degree

Master's Degree

Current Employment Status (mark all that apply)

Full Time Part Time Seasonally Employed Training

Student Unemployed Retired or Disabled

If not currently employed, when was the last time the Primary Adult worked?

Did this person file last year's 1040 U S Individual Income Taxes? (select one)

Yes No

Has the Primary Adult attended an educational institution such as UNR, TMCC, Milan Institute, Job Corps, GED preparation, etc. during the last 12 months? (select one)

Yes No

Relationship to Child Applying for Head Start (select one)

Biological Parent Stepparent by Marriage Foster Parent

Adoptive/Legal Guardian Grandparent Aunt or Uncle

Other:

SECONDARY Adult's Information - Part 1 These questions are for the OTHER parent/guardian LIVING IN THE

HOME who IS NOT the head of the household.

First Name MI Last Name



Yes No

Veteran (select one)

Yes No

In the Military (select one)

Yes No

Marital Status ((select one)

Married Legally Separated Single Divorced Widowed

Gender (select one)

Male Female



Race (select one)



Other:







Private Medicare VA/Tricare Other

Highest Level of Education (select one)

Grade 9 or Less High School Non-Graduate High School Diploma

GED Some College Associate's Degree Bachelor's Degree

Master's Degree

Current Employment Status (mark all that apply)

Full Time Part Time Seasonally Employed Training

Student Unemployed Retired or Disabled

If not currently employed, when was the last time the Secondary Adult worked?

Yes No

Has the Secondary Adult attended an educational institution such as UNR, TMCC, Milan Institute, Job Corps, GED preparation, etc. during the last 12 months? (select one)

Yes No

Relationship to Child Applying for Head Start (select one)

Biological Parent Stepparent by Marriage Foster Parent

Adoptive/Legal Guardian Grandparent Aunt or Uncle

Other:

Page 1 of 6


PRIMARY Adult's Information - Part 2 These questions are for the parent/guardian LIVING IN THE HOME who

is the HEAD OF HOUSHOLD.First Name MI Last Name

What types of money did this person have in the LAST 12 MONTHS? (MARK YES OR NO FOR ALL OF THE FOLLOWING)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Pay/Cash from Jobs, Work, Employment, or Self-Employment

Training Stipends

Unemployment Compensation

Worker's Compensation

Pension or Retirement

School Grants or Scholarships

Fellowships or Assistantships

Net Royalties

Dividends or Interest

Regular Insurance or Annuity Payments

Net Rental Income

Periodic Receipts from Estates or Trusts

Temporary Assistance for Needy Families (TANF) Cash Aid

Supplemental Secuirty Income (SSI) Cash Aid

Social Security

Veteran's Benefits

Child Support

Spousal Support or Alimony

Foster Care or Adoption Subsidy

Military Family Allotments

General Assistance or General Relief Money Payments

Emergency Assistance Money Payments

Gambling or Lottery Winnings

Regular Cash or Help From Friends or Family

Explain Other:

Undocumented cash includes; tips from your job, cash for labor or side jobs, babysitting, cleaning houses, yard work, cutting hair or doing nails, receiving regular cash help from friends or family, etc. Did this person receive any UNDOCUMENTED pay or cash during the last 12 month? (select one)

Yes No

SECONDARY Adult's Information - Part 2 These questions are for the OTHER parent/guardian LIVING IN THE

HOME who IS NOT the head of the household.First Name MI Last Name

What types of money did this person have in the LAST 12 MONTHS? (MARK YES OR NO FOR ALL OF THE FOLLOWING)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Pay/Cash from Jobs, Work, Employment, or Self-Employment

Training Stipends

Unemployment Compensation

Worker's Compensation

Pension or Retirement

School Grants or Scholarships

Fellowships or Assistantships

Net Royalties

Dividends or Interest

Regular Insurance or Annuity Payments

Net Rental Income

Periodic Receipts from Estates or Trusts

Temporary Assistance for Needy Families (TANF) Cash Aid

Supplemental Secuirty Income (SSI) Cash Aid

Social Security

Veteran's Benefits

Child Support

Spousal Support or Alimony

Foster Care or Adoption Subsidy

Military Family Allotments

General Assistance or General Relief Money Payments

Emergency Assistance Money Payments

Gambling or Lottery Winnings

Regular Cash or Help From Friends or Family

Explain Other:

Undocumented cash includes; tips from your job, cash for labor or side jobs, babysitting, cleaning houses, yard work, cutting hair or doing nails, receiving regular cash help from friends or family, etc. Did this person receive any UNDOCUMENTED pay or cash during the last 12 month? (select one)

Yes No

Page 2 of 6


Family Information All questions in this section pertain to the family applying for the CSA Head Start Program.

Living Address Unit/Space City State Zip Code

Mailing Address Unit/Space City State Zip Code

Primary Phone (9999999999)

Home Cell Work Message

Secondary Phone (9999999999)


Additional Phone (9999999999)


Email Address

What is your family's current housing situation? (select one)

Rent Own Homeless Explain Other:

Is your family living in someone else's home? (select one)

Yes No

Are you making any payments for housing or any payments for utilities? (select one)

Yes No

What type of dwelling does your family live in? (select one)

Apartment Single-family House Condo/Townhouse Duplex/Triplex/4-plex Mobile Home or Trailer Motel or Hotel Shelter

Park, Street, Car or Campsite

What is your family's current transportation situation? (select one)

Car Friend's or Relative's Car Public Transportation No Transportation

Is your family receiving any of the following services? (mark all that apply)

WIC Food Stamps/SNAP Energy Assistance Program (EAP) Section 8 Housing HUD Housing Assistance No services are being received

In addition to enrolling your child in Head Start, please indicate your top four (4) needs (mark up to 4)

Food Housing Clothing Medical Transportation Job Training or Placement Energy or Utility Assistance Tax Return Assistance

Explain Other:

How did you hear about Head Start? (select one)

CSA Head Start Flyer by Postal Mail Phone Book Internet Website Radio Television Family Friend Outside Agency Referral

Newspaper Community Events CSA Head Start Poster/Flyer CSA/Head Start Internal Referral

Please specify your family type (select one)

Two-parent Family Mother Figure Only/Single-parent Family Father Figure Only/Single-parent Family Grandparents Raising Grandchildren

Foster Family Other Relatives/Persons

Mother

How many people are living in the home? (write a number next to each) For example- Mother: 1 Father: 1 Other Adults: 1 Your children: 3 Other Children: 1

Father Other Adults Your Children Other Children

I hereby declare that the information contained in this application for program services is true and correct to the best of my knowledge and understanding. No false or is leading statements have been made by me or anyone representing me. The acceptance of the application DOES NOT guarantee that services will be performed under any program, and that services are dependent on many things including accurate applications, availability of finding and determination that the applicant qualifies for the program. I hereby release, discharge, and exonerate Community Services Agency, their agents and representatives and any person furnishing information or examining information from any all liability of every nature and kind arising out of the furnishing and inspection of such documents, records and other information, and this release shall be binding on my legal representatives, heirs and assigns. I additionally authorize Community Services Agency and their agents and representatives to use the information that I have provided and aggregated with other customers and clients of Community Services Agency for any and all reporting and funding purposes. Community Services Agency, its agents, partners and funding sources do not discriminate on the basis of color, sex, age, religion, national origin, disability, marital status, sexual orientation, ancestry, or any other consideration made unlawful by the applicable discrimination laws. The USDA is an equal opportunity provider and employer.

Applicant's Signature: Today's Date:

Program Applicant Disclosure Statement This application must be signed and dated by the applying parent/guardian in order to be processed.

Page 3 of 6

Agency Name:


Has child support or cash been received for this child in the last 12 months? (select one)

Who has legal custody of this child? (select one - CAREFULLY)

When was this child's last dental exam? (mmddyyyy)

When was this child's last physical exam or well check? (mmddyyyy)

Do you have any concerns that your child may have a special need or disability? (select one)

Information for the Child Applying for Head Start All questions in this section pertain to the child enrolling in the CSA Head Start Program.

First Name MI Last Name Birth Date (mmddyyyy)


Yes No Yes No

Gender (select one)

Male Female


Hispanic Non-HispanicRace (select one)

American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Unspecified

Other:






None Medicaid Nevada Check Up Indian Health Services(IHS) Private Other

If you selected Medicaid, what plan does this child Have? (mark all that apply)

Amerigroup Community Care Health Plan of Nevada Don't Know

Medical Insurance ID or Group Number

Does this child have a doctor? (select one)

Yes No

What is the name of this child's doctor, or the name of the medical office, address, and phone number?

Does this child have a dentist? (select one)

Yes No

What is the name of this child's dentist, or the name of the medical office, address, and phone number?

Does this child have ANY medical condition/allergy or HISTORY of a medical condition/allergy that would require medication, accommodation, or restriction in the classroom or during outside play; for example, HISTORY OF ASTHMA, ALLERGIES, SEIZURES, etc.? (select one)

Yes No

If yes, explain the condition:

When was then condition diagnosed?

Which doctor or medical office would have this condition on file?

Does this child take any medication? (select one)

Yes No

If yes, explain the medication:

Has you child been referred to the Head Start Program from a child welfare agency? (select one)Yes No

If yes, write which agency you have been referred from:

If yes, explain the concern:

Yes No

Page 4 of 6

Both biological parents are living in the same home as this child. Parents are separated & mother has custody. Parents are separated & father has custody.

Mother and father are separated but share joint custody. Other relative(s) or person(s) has/have custody or guardianship.

VA/Tricare


Preferred Center Location

1900 Sullivan Lane, Sparks 89431

2750 Elementary Drive, Reno 89512

1100 East 8th Street, Reno 89512

915 Farm District Road, Fernley 89408

5310 Echo Avenue, Stead 89506

650 Apple Street, Reno 89502

4950 Filbert Road, Reno 89502

1950 Villanova Drive, Reno 89502

Preferred Classroom TimeMorning Session

Afternoon Session

Extended Day Session

Full Day Session

8:00 a.m. to 11:30 a.m., Monday - Thursday

1:00 p.m. to 4:30 p.m., Monday - Thursday

8:00 a.m. to 1:00 p.m., Monday - Thursday Available only at Bernice Mathews

8:00 a.m. to 3:30 p.m., Monday - Thursday Available only at Bernice Mathews & Wooster

Second Choice Center Location










Afternoon Session


Full Day Session





Third Choice Center Location







Agnes Risley Center

Bernice Mathews Center

Central Office Center

Cottonwood Center

Desert Heights Center

Echo Loder Center

Smithridge Center

Wooster Center

Agnes Risley Center



Cottonwood Center


Echo Loder Center

Smithridge Center

Wooster Center

Agnes Risley Center



Cottonwood Center


Echo Loder Center

Smithridge Center

Wooster Center




Afternoon Session


Full Day Session





Program Selection Criteria This section will ask you to provide additional information regarding your family's situation.

Is the child applying for Head Start being referred by UNR's Early Head Start Program?

Yes No

Is the child applying for Head Start being referred by The Child Find Project and has an IEP?

Yes No

Has the child applying for Head Start ever been in foster care or in the custody of Social Services?

Yes No

Has the child applying for Head Start ever been subject to abuse and/or neglect or is at risk of violence?

Yes No

Is either parent/guardian currently incarcerated or has been incarcerated within the last 12 months?

Yes No

Is either parent/guardian of the applying child deceased?

Yes No

Has either parent/guardian had problems with alcohol or drug abuse within the last 12 months?

Yes No

Program Waitlist Preferences You are able to specify in this section which center and class time you would prefer for your child to be enrolled in or assigned to on the program waitlist.

Page 5 of 6

If yes, explain the disability or special need:


Relationship to Secondary Adult (select one)

Relationship to Primary Adult (select one)







Additional Children Living in the Home All questions in this section pertain to the other children living in the home who are related to the primary and secondary adults by blood, marriage, or adoption.




Yes No

Is child support received for this child? (select one) Yes No

Gender (select one)

Male Female



Race (select one)



Other:


English Spanish

Other


None Poor

Well Very Well



Private Other




Yes No

Is child support received for this child? (select one) Yes No

Gender (select one)

Male Female



Race (select one)



Other:


English Spanish

Other


None Poor

Well Very Well



Private Other




Yes No

Is child support received for this child? (select one)

Yes No

Gender (select one)

Male Female



Race (select one)



Other:


English Spanish

Other


None Poor

Well Very Well

Medical Insurance Coverage (mark all that apply)None Medicaid Nevada Check Up Indian Health Services(IHS)

Private Other




Yes No

Is child support received for this child? (select one)

Yes No

Gender (select one)

Male Female



Race (select one)



Other:


English Spanish

Other


None Poor

Well Very Well

Medical Insurance Coverage (mark all that apply)None Medicaid Nevada Check Up Indian Health Services(IHS)

Private Other

Page 6 of 6

VA/TricareVA/Tricare

VA/TricareVA/Tricare

Documents

Head Start Enrollment Application · CSA Head Start Enrollment Application. Revised 08/26/2014 ... Adult's Information - Part 1 These questions are for the OTHER parent/guardian LIVING