The Neighborhood Place for Early Head Start A division of the Early Learning Coalition of Miami-Dade/Monroe

6251 NW 7th Avenue Suite 204 Miami, Florida 33150 (305) 646-7220 ext. 2457

(REVISED 4/1/2020)

Thank you for your interest in The Neighborhood Place for Early Head Start Program (TNPEHS). Our program offers full day preschool and family services at various locations throughout Miami-Dade County. To qualify for our services, your child must be age and income eligible. Submitting this application does not guarantee acceptance into Early Head Start, priority will be given based on a point system. ELIGIBILITY REQUIREMENTS Age Eligibility: For Early Head Start - Your child must be under 3 years of age. Income Eligibility: Your family is income eligible if your income meets 100% of the 2020 Federal Income Guidelines:

For families/households with more than 8 members, add $4,480 for each additional person. SUBMITTING YOUR APPLICATION Once you have completed the application, you may submit your materials in one of the following ways:

Visit the Central Service Center, United Way Building, 3250 SW 3rd Avenue, Miami, Florida 33129 Visit the North Service Center, Golden Glades Office Park, 1515 NW 167 th Street, Suite 320 Miami Gardens, Florida 33169

Visit the South Service Center, The Centre at Cutler Bay Condominium, 18951 SW 106 Ave, Unit B-208, Miami, Florida 33157 Visit the Edison Office, Edison Marketplace, 6251 NW 7th Avenue, Ste. 204, Miami, Florida 33150

You will be contacted by email once your application has been processed.

SIZE OF FAMILY UNIT GROSS ANNUAL INCOME

1 $ 12,760

2 $ 17, 240

3 $ 21,720

4 $ 26,2005 $30,680

6 $35,1607 $39,6408 $44,120

Visit the Provider of your choice to complete an application for services.

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2019-2020 Selection Criteria

Criteria Points

A. Income

Low Income 0 – 25% of the Poverty Guidelines 100

Low Income 26% – 50% of the Poverty Guidelines 95

Low Income 51% –75% of the Poverty Guidelines 85

Low Income 76% – 100% of the Poverty Guidelines 75

B. Age

0 - 11 months 150

12 months – 2 years old 100

2 years and 1 month – 3 years old 80

C. Disability

Diagnosed Disability with IFSP 375

Condition Diagnosed by a Professional 230

Identified as having concerns through a screener by qualified professional 50

Parental Concern 50

D. School Readiness

BG-8 250

BG-5 230

BG-3 200

BG-1 175

Waitlisted applicants 100

E. Parental Status

Foster Parent 100

Legal Guardian 95

One Parent Family 90

Two Parent Family 60

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F. Other Factors

Documented Homeless 230

Documented Incarcerated Parents 150

Documented SSI/TANF Recipients 150

Families with prior DCF history 100

Documented Disaster Evacuee 100

Documented Impacted by Gun Violence 100

Documented Substance Abuse 90

Documented Domestic Violence 90

Documented DCF Referral and Court Order 90

Undocumented Domestic Violence referred by partnering agency 50

Referral from partnering agency 50

Documented Student 80

Documented Working Parent 80

Documented Teen Parent 75

Documented Sibling of Returning Student 75

Documented Migrant Seasonal Farm Worker 75

Documented Public Housing Resident 75

Documented Infant Mortality 50

Documented Pregnant Woman 50

Postpartum Depression 50

Enrolled in Current Center 50

The Neighborhood Place for Early Head Start A division of the Early Learning Coalition of Miami-Dade/Monroe

EHS PARTNERS BY COMMUNITIES

NORTH Liberty City

It’s a Small World Learning Center II 3100 NW 94th Street 33147 (305) 696-1234

It’s a Small World Learning Center VII 8601 NW 22nd Avenue 33147 (305) 691-2665

Liberty Academy Daycare and Preschool, Inc. 7750 NW 12th Avenue 33150 (305) 696-8100

Lincoln Marti 10203 NW 21st Court 33147 (305) 693-2225

LORD’s Learning Center, Inc. 17 NW 84th Street 33150 (305) 756-6119

Sheyes of Miami Day Care #3 4801 NW 7th Avenue 33127 (305) 754-4087

Sheyes of Miami Learning Center 3038 NW 48th Terrace 33142 (305) 634-6268

Shores School 545 NW 95th Street 33150 (305) 751-0101

Step Above Academy 750 NW 96th Street 33150 (305) 836-5723

The Carter Academy 10200 NW 22nd Avenue 33147 (305) 693-3555

The Carter Academy II 1910 NW 95th Street 33147 (305) 342-3448

Wynwood Learning Center II 5580 NW 7th Avenue 33127 (305) 603-8865

Opa-Locka

America’s Little Leader Christian Academy 2570 NW 152nd Terrace 33054 (786) 332-4698

Cambridge Academy & Camp Learning Center, Inc. 2750 NW 167th Street 33054 (305) 625-5437

Children of the Sun Academy, Inc. 1360 Kasim Street 33054 (305) 688-9088

Little Ones Academy 2527 Opa-Locka Boulevard 33054 (786) 238-7005

Miami Gardens Learning Center 16600 NW 25th Avenue 33054 (305) 623-4000

Pink and Blue Children’s Academy 1840 NW 152nd Terrace 33054 (305) 681-0616

SOUTH Little Havana

Kids Small World Learning Center 3360 W Flagler Street 33135 (305) 567-0661

Lincoln Marti 450 SW 16th Avenue 33135 (305) 643-2626

Lincoln Marti 905 SW 1st Street 33130 (305) 325-2000

Rainbow Intergenerational Learning Center 700 SW 8th Street 33130 (305) 285-3263

Hialeah New Aladdin Learning Ceter 5932 W 16th Avenue 33012 (305) 362-0016

Springview Academy of Hialeah 55 W 29th Street 33012 (305) 381-5768

Homestead Little Red School House of Homestead 159 NE 9th Street 33030 (305) 248-2229

My Little Angels Daycare Center 280 S Krome Avenue 33030 (305) 242-3646

Naranja Prep Academy Annex 310 NE 2nd Drive 33030 (786) 601-9560

Florida City Kinderkids Academy III 40 NW 5th Avenue 33034 (786) 339-9244

Kinderland 4 Kids, LLC 35 SW 6th Avenue 33034 (786) 243-2556

Our Little Hands of Love, Inc. 489 W Lucy Street 33034 (305) 248-6222

Precious Moments Learning Center 580 Davis Parkway 33034 (305) 245-5954

Early Head Start Enrollment Application

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INSTRUCTIONS: Please carefully read and accurately complete every section of this application. Anything that does not apply to you write “N/A”. Applications with incomplete, false, or inaccurate information will not be entered in the system or considered for selection. Please be advised that providing false information or income omissions may be grounds for rejection of this application or termination of childcare services.

APPLICATION DATE:

LOCATION (SCHOOL) PREFERENCE: (Note - if you do not select any school you will not be placed on a waiting list anywhere)

Choice #1 Choice #2 Choice #3

APPLICANT (Child’s Information)

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

*RACE: *ETHNICITY:

☐ American Indian/Alaskan ☐ Asian ☐ Black/African American

☐ Pacific Islander/Hawaiian ☐ White

☐ Other (Bi-Racial/Multiracial):

☐ Hispanic/Latino

☐ Non-Hispanic/Non-Latino

ENGLISH PROFICIENCY:

☐ None/Nonverbal ☐ Little ☐ Moderate ☐ Proficient

OTHER LANGUAGE (SPECIFY):

OTHER LANGUAGE PROFICIENCY:

☐ Little ☐ Moderate ☐ Proficient

*PRIMARY HEALTH COVERAGE: ☐ Children’s Health Insurance Program (CHIP) – FL Kid Care ☐ Combined Medicaid/CHIP

☐ Medicaid ☐ No Insurance ☐ Private Health Insurance

☐ State-Only Funded Insurance ☐ Other:

OTHER HEALTH COVERAGE: ☐ Children’s Health Insurance Program (CHIP) – FL Kid Care ☐ Combined Medicaid/CHIP

☐ Medicaid ☐ No Other Insurance ☐ Private Health Insurance

☐ State-Only Funded Insurance ☐ Other:

MEDICAID ELIGIBILITY STATUS: ☐ Not Eligible ☐ On Medicaid ☐ Potentially Eligible

INSURANCE OR MEDICAID NUMBER:

*NAME OF DOCTOR/MEDICAL HOME:

DOCTOR/MEDICAL PHONE NUMBER:

DENTAL COVERAGE: ☐ Children’s Health Insurance Program (CHIP) – FL Kid Care ☐ Combined Medicaid/CHIP

☐ Medicaid ☐ No Insurance ☐ Private Health Insurance

☐ State-Only Funded Insurance ☐ Other:

DENTAL COVERAGE NUMBER:

*NAME OF DENTIST/DENTAL HOME:

DENTIST/DENTAL PHONE NUMBER:

Do you live in Miami-Dade County? Are you currently homeless? Does your child have a diagnosed disability and has an IFSP?

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

Is child enrolled in School Readiness?

If yes, what date did you become eligible?

What is your School Readiness expiration date?

If not enrolled in School

Readiness, have you applied?

If yes, what date did you apply?

☐ Yes ☐ No ☐ Yes ☐ No

Early Head Start Enrollment Application

Page 2 of 10

FAMILY MEMBERS

PRIMARY ADULT

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

*RACE: *ETHNICITY:

☐ American Indian/Alaskan ☐ Asian ☐ Black/African American ☐ Pacific Islander/Hawaiian

☐ White ☐ Other (Bi-Racial/Multiracial):

☐ Hispanic/Latino

☐ Non-Hispanic/Non-Latino

EMAIL ADDRESS:

ENGLISH PROFICIENCY:

☐ None ☐ Little ☐ Moderate ☐ Proficient

OTHER LANGUAGE (SPECIFY): OTHER LANGUAGE PROFICIENCY:

☐ Little ☐ Moderate ☐ Proficient

*HIGHEST GRADE

COMPLETED: ☐ Less than high school ☐ Some college ☐ Associates Degree

☐ Some High School (specify grade completed): _____ ☐ Advance Training ☐ Bachelor’s Degree

☐ High School Grad ☐ Training Certificate ☐ Master’s Degree

☐ GED ☐ Doctoral Degree

*EMPLOYMENT: ☐ Full-time & Training ☐ Full-time (35 hrs/wk or more)

☐ Part-time & Training ☐ Part-time (less than 35 hours) ☐ Training or School

☐ Retired or Disabled ☐ Seasonally Employed ܆ ☐ Unemployed

RELATIONSHIP TO CHILD: ☐ Biological/Adopted/Step ☐ Foster ☐ Grandchild ☐ Other/Other Relative (specify):

MARITAL STATUS LEGAL CUSTODY LIVES WITH

FAMILY

PROVIDES FINANCIAL

SUPPORT

TEEN PARENT INCARCERATED

PARENT

☐ Married ☐ Single ☐ Widow ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

SECOND ADULT

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

*RACE: *ETHNICITY:

☐ American Indian/Alaskan ☐ Asian ☐ Black/African American ☐ Pacific Islander/Hawaiian

☐ White ☐ Other (Bi-Racial/Multiracial):

☐ Hispanic/Latino

☐ Non-Hispanic/Non-Latino

EMAIL ADDRESS:

ENGLISH PROFICIENCY:

☐ None ☐ Little ☐ Moderate ☐ Proficient

OTHER LANGUAGE (SPECIFY): OTHER LANGUAGE PROFICIENCY:

☐ Little ☐ Moderate ☐ Proficient

*HIGHEST GRADE

COMPLETED: ☐ Less than high school ☐ Some college ☐ Associates Degree

☐ Some High School (specify grade completed): _____ ☐ Advance Training ☐ Bachelor’s Degree

☐ High School Grad ☐ Training Certificate ☐ Master’s Degree

☐ GED ☐ Doctoral Degree

*EMPLOYMENT: ☐ Full-time & Training ☐ Full-time (35 hrs/wk or more)

☐ Part-time & Training ☐ Part-time (less than 35 hours) ☐ Training or School

☐ Retired or Disabled ☐ Seasonally Employed ܆ ☐ Unemployed

RELATIONSHIP TO CHILD: ☐ Biological/Adopted/Step ☐ Foster ☐ Grandchild ☐ Other/Other Relative (specify):

MARITAL STATUS LEGAL CUSTODY LIVES WITH

FAMILY

PROVIDES FINANCIAL

SUPPORT

TEEN PARENT INCARCERATED

PARENT

☐ Married ☐ Single ☐ Widow ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

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Early Head Start Enrollment Application

LIST ADDITIONAL FAMILY MEMBERS SUPPORTED BY THE HOUSEHOLD INCOME

(ADDITIONAL MEMBERS SUPPORTED BY THE HOUSEHOLD INCOME CAN BE ADDED ON PAGE 7)

1.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

2.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

3.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

FAMILY INFORMATION

LIVING ADDRESS:

CITY: STATE: ZIP CODE: COUNTY:

MAILING ADDRESS:

CITY: STATE: ZIP CODE: COUNTY:

PHONE #: TYPE: WHOSE NUMBER

☐ Cell ☐ Home ☐ Work

PHONE #: TYPE: WHOSE NUMBER

☐ Cell ☐ Home ☐ Work

PHONE #: TYPE: WHOSE NUMBER

☐ Cell ☐ Home ☐ Work

*PARENTAL STATUS: *PRIMARY LANGUAGE SPOKEN AT HOME: *IS THE FAMILY HOMELESS? *REFERRED BY CHILD WELFARE AGENCY

(specify)?

☐ One Parent Family

☐ Two Parent Family

☐ Yes ☐ No

*AT LEAST ONE

PARENT/GUARDIAN IS AN ACTIVE

MEMBER OF THE U.S. MILITARY?

*AT LEAST ONE PARENT/GUARDIAN

IS A VETERAN OF THE U.S. MILITARY?

*RECEIVING SNAP: *RECEIVING

WIC?

WIC NUMBER:

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

IS ANYONE IN THE FAMILY AN EMPLOYEE OF THE

EARLY LEARNING COALITION OF MIAMI- DADE/MONROE?

☐ Yes ☐ No IF SO, WHAT DEPARTMENT

DO YOU WORK:

IS ANYONE IN THE FAMILY RELATED TO AN EARLY

LEARNING COALITION OF MIAMI-DADE MONROE? ☐ Yes ☐ No IF SO, WHICH EMPLOYEE:

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Early Head Start Enrollment Application

FAMILY INCOME

INCOME SOURCES TANF (CASH ASSISTANCE) STATUS: ☐Yes ☐No ☐Formerly on TANF/Not now MONTHLY AMOUNT OF

TANF? $

DO YOU OR A FAMILY MEMBER LIVING WITH AND SUPPORTED BY YOU RECEIVE SUPPLEMENTAL SECURITY INCOME BENEFITS (SSI)? ☐Yes ☐ No

IF SO, WHO? MONTHLY AMOUNT OF SSI? $

DO YOU OR A FAMILY MEMBER

RECEIVE CHILD SUPPORT? ☐Yes

☐No

IS CHILD SUPPORT

COURT ORDERED? ☐Yes ☐No ☐ N/A MONTHLY AMOUNT OF CHILD

SUPPORT? $

DO YOU OR A FAMILY MEMBER

RECEIVE A PENSION? ☐Yes

☐No

IF YES, SPECIFY:

MONTHLY AMOUNT? $

DO YOU HAVE ANY OTHER SOURCE OF

INCOME? ☐Yes

☐No

IF YES, SPECIFY:

MONTHLY AMOUNT? $

EMPLOYMENT INFORMATION/INCOME INFORMATION FOR THE PAST 12 MONTHS

1.

SELECT THE WORKING ADULT FROM THE DROP-DOWN

IF WORKING ADULT IS NOT THE PRIMARY OR

SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:

EMPLOYER: OCCUPATION:

HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment

WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month

2.

SELECT THE WORKING ADULT FROM THE DROP-DOWN

IF WORKING ADULT IS NOT THE PRIMARY OR

SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:

EMPLOYER: OCCUPATION:

HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment

WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month

3.

SELECT THE WORKING ADULT FROM THE DROP-DOWN

IF WORKING ADULT IS NOT THE PRIMARY OR

SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:

EMPLOYER: OCCUPATION:

HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment

WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month

4.

SELECT THE WORKING ADULT FROM THE DROP-DOWN

IF WORKING ADULT IS NOT THE PRIMARY OR

SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:

EMPLOYER: OCCUPATION:

HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment

WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month

5.

SELECT THE WORKING ADULT FROM THE DROP-DOWN

IF WORKING ADULT IS NOT THE PRIMARY OR

SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:

EMPLOYER: OCCUPATION:

HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment

WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month

Number of people living in the house: Number of people supported by the parent or guardian’s income:

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Early Head Start Enrollment Application

FAMILY CIRCUMSTANCES

Please answer each item with “Yes” or “No.” Documentation must be provided for any item answered “Yes.”

Does the child have medical issues (prematurity, failure to thrive, spina bifida)? ☐ Yes ☐ No

Does the child have a diagnosed condition by a professional? ☐ Yes ☐ No

DO ANY OF THE FOLLOWING APPLY TO YOUR FAMILY? (Please refer to page 8 for items requiring documentation)?

1. Homeless ☐ Yes ☐ No

2. Incarcerated Parents ☐ Yes ☐ No

3. SSI/TANF Recipients ☐ Yes ☐ No

4. Families with prior DCF History ☐ Yes ☐ No

5. Disaster Evacuee ☐ Yes ☐ No

6. Impacted by Gun Violence ☐ Yes ☐ No

7. Substance Abuse ☐ Yes ☐ No

8. DCF Referral and Court Order ☐ Yes ☐ No

9. Domestic Violence ☐ Yes ☐ No

10. Parent is Enrolled in School ☐ Yes ☐ No

11. Working Parent ☐ Yes ☐ No

12. Teen Parent ☐ Yes ☐ No

13. Sibling of Returning Student ☐ Yes ☐ No

14. Migrant Seasonal Farm Worker ☐ Yes ☐ No

15. Public Housing Resident ☐ Yes ☐ No

16. Infant Mortality ☐ Yes ☐ No

17. Pregnant Woman ☐ Yes ☐ No

18. Postpartum Depression ☐ Yes ☐ No

19. Enrolled in Current Center ☐ Yes ☐ No

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Early Head Start Enrollment Application

FAMILY EMERGENCY CONTACTS

CHILD’S NAME: CHILD’S DATE OF BIRTH PARENT/GUARDIAN’S NAME:

EMERGENCY CONTACTS: Child will be released only to the custodial parent or legal guardian and the people listed below. The people below will also be contacted and are authorized to remove the child from the facility in case of illness, accident, or emergency. This form must be updated as changes occur.

1.

NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent

☐ Other

ADDRESS: CITY: STATE: ZIP CODE:

PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:

☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work

2.

NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent

☐ Other

ADDRESS: CITY: STATE: ZIP CODE:

PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:

☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work

3.

NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent

☐ Other

ADDRESS: CITY: STATE: ZIP CODE:

PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:

☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work

4.

NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent

☐ Other

ADDRESS: CITY: STATE: ZIP CODE:

PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:

☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work

5.

NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent

☐ Other

ADDRESS: CITY: STATE: ZIP CODE:

PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:

☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work

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Early Head Start Enrollment Application

ADDITIONAL FAMILY MEMBERS

4.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

5.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

6.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

7.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

8.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

9.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

10.

FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:

NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN

☐ Male ☐ Female

RELATIONSHIP:

☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other

Page 8 of 10

Early Head Start Enrollment Application

REGISTRATION REQUIREMENTS

All Yellow Items Are Required Check off documents being submitted (to be checked off by parent)

Person receiving application, please write date received

Proof of Age: ☐ Birth Certificate

☐ Passport

☐ Notarized Affidavit of Age

☐ Immunization Record

Proof of parent’s/legal guardian gross income for the past 12 months or the last calendar year

Important: Submit document(s) as proof of income for each person contributing to the family income or for multiple jobs.

☐ Signed Income Form Tax 1040 with correct household size

☐ W-2 forms

☐ Pay stubs (proof for the last 6 weeks)

☐ Unemployment Compensation

☐ Written statements from employers (letterhead)

☐ Social Security Supplemental Income (SSI) printouts

☐ Public Assistance (TANF) Printouts

☐ Child Support

☐ Notarized Income Statement

Proof of Parent’s Identification ☐ Driver’s license/Passport/ID from Homeless Shelter

☐ State issued picture I.D.

☐ Employer issued I.D.

☐ Military ID

Proof of Dade County Residency ☐ Driver’s license with address listed

☐ State issued picture I.D. with address listed

☐ Utility Bills/Statements (lights, phone, cable, etc.)

☐ Lease Rental /Mortgage Agreement

☐ Employer Record (Paystub)

Submit proof only if applicable Support Documents Date Received

School Readiness Enrollment ☐ Non-Transferable Child Care Certificate for School Readiness

School Readiness Waitlist ☐ Waitlist Confirmation Email

Disability (applicant child) ☐ Individualized Family Support Plan (IFSP)

Suspected Disability (applicant child) ☐ Doctor’s/Therapist’s Statement outlining concerns

Substance Abuse ☐ Written Statement from Treatment Program

Domestic Violence ☐ Written Statement from Domestic Violence Agency/Court

☐ Referral from Partnering Agency if Undocumented Domestic Violence

DCF Referred and Court Order ☐ DCF Referral/Court Order

Prior DCF History ☐ DCF or Court Order document of prior case

Student (Parent) ☐ Current transcripts/schedule

Pregnant Woman ☐ Written Medical Documentation (current)

Public Housing Resident ☐ MDPHA Written Rental/Lease Agreement

Incarcerated Parent ☐ Sentencing Order/Signed Affidavit or Letter from Prison

Enrolled in Current Center ☐ Statement from Owner of Child Care Center

Disaster Evacuee ☐ Notarized declaration letter from parent/ FEMA Documentation

Impacted by Gun Violence ☐ Police Report (if available)

Infant Mortality ☐ Death Certificate (if available)

Postpartum Depression ☐ Doctor’s letter with diagnosis (if available)

Homeless ☐ Written Statement from Homeless Facility (if available)

Foster Care/Legal Custody ☐ Documentation from Foster Care Agency/ Court Award

Guardianship/Legal Custody ☐ Documentation from Court System/ Court Award

Referred by Partnering Agency ☐ Referral from Partnering Organization

Page 9 of 10

Early Head Start Enrollment Application

Acknowledgement

Important:

Please read carefully before signing.

• I certify that the information provided in this application package and all

supporting documentation are accurate and truthful.

• I certify that all sources of income supporting the household have been reported

and corresponding proof has been submitted according to program

requirements.

• I understand that providing false information or income omissions to qualify for

the program may be grounds for rejection of this application or termination from

the program.

• I will notify the program immediately if there are any changes to my contact

information, income, or family circumstances.

• I understand incomplete applications will not be accepted.

Signature Instructions (Important) • Printed Applications:

If you completed this application manually, please sign with a pen on the Parent/Guardian Signature (eSignature) line below.

• Electronic Applications:

If you completed this application on the computer and are submitting via email, please type your first and last name after the “/s/” on the Parent/Guardian Signature (eSignature) line below. By typing your first and last name after “/s/”, you understand that it is an electronic signature that has the same legal effect as a manual signature.

Parent/Guardian Signature (eSignature): /s/ _____

Date:

Page 10 of 10

Early Head Start Enrollment Application

For Eligibility and EHS Use only:

Eligibility Verification

Child’s Name: DOB:

This child is eligible to participate in the program: ☐ Yes ☐ No

Family Size: (Supported by the income of the parent(s) or legal guardian)

Total Family Income:

Check the applicable category of eligibility for this child ☐ Homeless

☐ Foster Care

☐ Public Assistance

Income (check box that applies): ☐ Below federal poverty guidelines

☐ Between 100-130% of federal poverty guidelines (no more than 35% of enrolled children may fall into this category)

Over-Income: ☐ Counted as part of 10% maximum for non-AI/AN programs

☐ Counted as part of the 49% maximum for non-AI/AN programs

What type of documentation was used to determine eligibility? ☐ Income Tax Form 1040 ☐ ELC Verification of Income ☐ EHS Declaration of Income

☐ W-2 ☐ ELC Work Calendar ☐ Child Support

☐ TANF Documentation ☐ Employer Letter ☐ 1099 – Misc.

☐ Pay stubs or pay envelopes ☐ Foster care – Court Order ☐ Other

☐ Unemployment Benefits ☐ SSI Documentation If Other, please explain:

Relevant Time Period for Income: ☐ Current Year ☐ Previous 12 months

I have examined the income documents checked off above and verify that the child is income and age eligible to participate in the program. Disciplinary action will be taken against staff that intentionally violate federal and program eligibility determination regulations by enrolling families that are not eligible to receive Early Head Start services. Signature of Staff Entering Applications: (Electronic Signature Acceptable)

Date of eligibility verification:

Staff Name (Print or Type):

Staff Title:

Signature of Secondary: (Electronic Signature Acceptable)

Date of eligibility verification:

Secondary Staff Name (Print or Type):

Secondary Staff Title:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .08 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.