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

Page 1 of 11 (REVISED 3/9/2017)

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 2018 Federal Income Guidelines:

For families/households with more than 8 members, add $4,320 for each additional person. SUBMITTING YOUR APPLICATION Once you have completed the application, you may submit your materials in one of the following ways:

Central Service Center, United Way Building, 3250 SW 3rd Avenue, Miami, Florida 33129 North Service Center, Golden Glades Office Park, 1515 NW 167 th Street, Suite 320 Miami Gardens, Florida 33169 South Service Center, The Centre at Cutler Bay Condominium, 18951 SW 106 Ave, Unit B-208, Miami, Florida 33157 Visit the Provider of your choice to complete an application for services.

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

SIZE OF FAMILY UNIT GROSS ANNUAL INCOME

1 $ 12,140

2 $ 16, 460

3 $ 20,780

4 $ 25,100

5 $29,420

6 $33,740

7 $38,060

8 $42,380

2018-2019 Recruitment and Selection Plan

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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

Parental Concern 50

D. School Readiness

BG-8 250

BG-5 230

BG-3 200

BG-1 175

Applicant 50

E. Parental Status

Foster Parent 100

Legal Guardian 95

One Parent Family 90

Two Parent Family 60

F. Other Factors

Documented Homeless 230

Documented Incarcerated Parents 150

Documented SSI/TANF Recipients 150

Documented Disaster Evacuee 100

Documented Impacted by Gun Violence 100

Documented Referral 90

Documented Substance Abuse/Domestic Violence 90

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

Enrolled in Current Center 50

 The Neighborhood Place for Early Head Start 

 

EHS PROVIDERS BY COMMUNITIES 

NORTH Liberty City 

Creative Kidz Preparatory Academy  4439 NW 7th Ave.   33127  305‐603‐8641 

Liberty Academy Daycare  7750 NW 12th Avenue   33150  305‐696‐8100 

LORD’s Learning Center  17 NW 84th Street   33150  305‐756‐6119 

Sheyes of Miami #1  6043 NW 6th Court   33127  305‐758‐7167 

Sheyes of Miami #3  4801 NW 7th Avenue   33127  305‐754‐4087 

Sheyes of Miami Learning Center Inc. #4  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  1910 NW 95th Street 33147  305‐ 456‐9898

The Carter Academy II  10200 NW 22nd Avenue 33147  305‐693‐3555

Wynwood Learning Center  231 NW 52nd Street   33142  786‐558‐9961 

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  2750 NW 167th Street   33054  305‐625‐5437 

Children of the Sun Academy  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

SouthLittle Havana 

Kids Small World  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 Childcare  700 SW 8th Street   33130  305‐285‐3263 

Homestead 

Le Jardin Community Center  177 W Mowry Drive 33030  305‐245‐4994

Little Red School House  159 NE 9th Street   33030  305‐248‐2229 

My Little Angels Daycare  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  35 SW 6th Avenue   33034  786‐243‐2556 

Our Little Hands of Love  489 W Lucy Street   33034  305‐248‐6222 

Precious Moments Learning Center  580 Davis Parkway   33034  305‐245‐5954 

 

FORM

Early Head Start Enrollment Application 6500 Part I

Page 4 of 11 (REVISED 3/9/2017)

APPLICATION DATE: ________________________

LOCATION (SCHOOL) PREFERENCE:

Choice #1 Choice #2 Choice #3

In what language would you like to receive written information? □ English □ Spanish □ Haitian Creole

APPLICANT (Child’s Information)

Full Name: (First, Middle, Last, Suffix)

Date of Birth:

Nickname: Social Security Number:

Race: □ Asian □ Black/African American □American Indian/Alaskan □ White □ Pacific Islander/Hawaiian □ Other (Bi-Racial/Multiracial): ____________________

Gender: □ Male □ Female Ethnicity: □ Hispanic/Latino □ Non-Hispanic/Non-Latino

English Proficiency: □ Little □ Moderate □ None □ Proficient Other Language:

Other Proficiency: □ Little □ Moderate □ None □ Proficient

Child Will Transition To:

□ Head Start □ Medical Services Provider □ Pre-School Classroom (Current Provider) □ Relative Care □ Pre-School Classroom (Different Provider) □ Home School □ Miami-Dade County Public Schools

Living Address:

City: State: Zip

Mailing Address: (if different)

City: State: Zip

Home Telephone Number:

Mobile Telephone Number: Work Telephone Number:

Parental Status: □ One Parent Family □ Two Parent Family □ Biological/Adopted/Step Parent □ Foster Parent/Legal Guardian □ Grandparent

Primary Language at Home: □ English □ Spanish □ Creole □ Other _____________________

*Family is Currently Homeless □ Yes □ No

At least one parent/guardian is an active member of the U.S. military? □ Yes □ No At least one parent/guardian is a veteran of the U.S. military? □ Yes □ No

*Referred by Child Welfare Agency: □ Yes □ No

*Receiving SNAP? □ Yes □ No

*WIC: □ Yes □ No

WIC ID Number:

Application Referral Source (Required):

□ Camillus House □ Easter Seals □ MDCPS □ CareerSource □ Early Learning Coalition □ Non-Profit Organization Partnership □ Chapman (HAC) □ Early Steps □ Nurse Family □ CHI □ Family/Friend Referral □ Opa-Locka CDC □ Children of Inmates □ Former Parent □ Public Housing □ Clinic □ Head Start □ Youth Co-Op □ Community Outreach □ Hospital □ WIC □ Cuban National □ Lotus House □ Walking One-Stop □ Current EHS Provider □ MCI □ Other (specify): ________________________

FORM

Early Head Start Enrollment Application 6500 Part I

Page 5 of 11 (REVISED 3/9/2017)

FAMILY INFORMATION

Parent/Guardian Full Name: Date of Birth: Relationship to Child:

Gender: □ Male □ Female Social Security Number:

Race: □ Asian □ Black/African American □American Indian/Alaskan □ White □ Pacific Islander/Hawaiian □ Other (Bi-Racial/Multiracial): ____________________

Ethnicity: □ Hispanic/Latino □ Non-Hispanic/Non-Latino

English Proficiency: □ Little □ Moderate □ None □ Proficient

Other Language Proficiency: □ Little □ Moderate □ None □ Proficient

Email:

Highest Grade: □ Less than high school ___________________ □ Some High School □ High School Grad or GED □ Some college or AA/AS □ Bachelor’s Degree □Master’s Degree □ Doctoral Degree

Legal Custody: □ Yes □ No Lives with Family: □ Yes □ No Provides Financial Support: □ Yes □ No Employed: □ Unemployed: □ Incarcerated Parent: □ Yes □ No

Second Parent/Guardian Full Name: (First, Middle, Last) Date of Birth: Relationship to Child:

Gender: □ Male □ Female Social Security Number:

Race: □ Asian □ Black/African American □American Indian/Alaskan □ White □ Pacific Islander/Hawaiian □ Other (Bi-Racial/Multiracial): ____________________

Ethnicity: □ Hispanic/Latino □ Non-Hispanic/Non-Latino

English Proficiency: □ Little □ Moderate □ None □ Proficient

Other Language: Proficiency: □ Little □ Moderate □ None □ Proficient

Email:

Highest Grade: □ Less than high school ___________________ □ Some High School □ High School Grad or GED □ Some college or AA/AS □ Bachelor’s Degree □ Master’s Degree □ Doctoral Degree

Legal Custody: □ Yes □ No Lives with Family: □ Yes □ No Provides Financial Support: □ Yes □ No Employed: □ Unemployed: □ Incarcerated Parent: □ Yes □ No

List all other family members living in the household for whom you are responsible for the care and welfare of that ARE NOT LISTED ABOVE: (For additional family members, please complete Attachment 1)

1. Full Name: (First, Middle, Last) DOB: □ Sibling □ Aunt/Uncle □Grandparent □ Other ________________________

Gender: □ Male □ Female Last 4 of SSN:

2. Full Name: (First, Middle, Last) DOB: □ Sibling □ Aunt/Uncle □Grandparent □ Other ________________________

Gender: □ Male □ Female Last 4 of SSN:

3. Full Name: (First, Middle, Last) DOB: □ Sibling □ Aunt/Uncle □Grandparent □ Other ________________________

Gender: □ Male □ Female Last 4 of SSN:

4. Full Name: (First, Middle, Last) DOB: □ Sibling □ Aunt/Uncle □Grandparent □ Other ________________________

Gender: □ Male □ Female Last 4 of SSN:

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

FORM

Early Head Start Enrollment Application 6500 Part I

Page 6 of 11 (REVISED 3/9/2017)

Family Income

*TANF (Cash Assistance) Status: □ Within Last 6 Months TANF □ Yes □ No If YES, amount per month: $

*Do you or a family member living with and supported by you receive Supplemental Security Income benefits (SSI)? □ Yes □ No

Parent/Guardian Second Parent/Guardian

Full Name: (First, Middle, Last)

Full Name: (First, Middle, Last)

Marital Status: □ Married □ Single □ Separated □ Divorced □ Widowed

Marital Status: □ Married □ Single □ Separated □ Divorced □ Widowed

Are you an employee of the Early Learning Coalition of Miami-Dade/Monroe? □ Yes □ No

Are you an employee of the Early Learning Coalition of Miami-Dade/Monroe? □ Yes □ No

Are you related to an Early Learning Coalition of Miami-Dade Monroe? □ Yes □ No

Are you related to an Early Learning Coalition of Miami-Dade Monroe? □ Yes □ No

Employment/Income Information for the past 12 months

Current Employer Name: Hire Date: Current Employer Name: Hire Date:

Occupation: Occupation:

□ Full-time □ Part-time Total hours per week: _____ □ Full-time □ Part-time Total hours per week: _____

Pay days are: □ Weekly □ Every 2 weeks □ Twice per month □ Monthly Gross Income: $___________ per_____________________

Pay days are: □ Weekly □ Every 2 weeks □ Twice per month □ Monthly Gross Income: $___________ per_____________________

Previous Employer Name: Hire Date: End Date: Previous Employer Name:

Hire Date: End Date:

Occupation:

□ Full-time □ Part-time Total hours per week: _____ □ Full-time □ Part-time Total hours per week: _____

Pay Frequency: □ Weekly □ Bi-Weekly □ Semi-Monthly □ Monthly Gross Income: $_____________________ per____________

Pay Frequency: □ Weekly □ Bi-Weekly □ Semi-Monthly □ Monthly Gross Income: $________________________ per_____________

Previous Employer Name:

Hire Date: End Date: Previous Employer Name:

Hire Date: End Date:

Occupation: Occupation:

□ Full-time □ Part-time Total hours per week: _____ □ Full-time □ Part-time Total hours per week: _____

Pay Frequency: □ Weekly □ Bi-Weekly □ Semi-Monthly □ Monthly Gross Income: $___________ per_____________________

Pay Frequency: □ Weekly □ Bi-Weekly □ Semi-Monthly □ Monthly Gross Income: $___________ per_____________________

*Do you receive child support? □ Yes □ No If YES, amount per month: $ _______________________ Is child support court ordered? □ Yes □ No

*Do you receive child support? □ Yes □ No If YES, amount per month: $ _______________________ Is child support court ordered? □ Yes □ No

Do you have any other sources of income: □ Yes □ No If YES, description: _________________________________ If YES, amount per month: $

Do you have any other sources of income: □ Yes □ No If YES, description: _________________________________ If YES, amount per month: $

Education Information

Are you in School or Training: □ Yes □ No Are you in School or Training: □ Yes □ No

School Name: School Name:

□ Full-time □ Part-time Total hours per week: _____

□ Full-time □ Part-time Total hours per week: _____

Occupation:

FORM

Early Head Start Enrollment Application 6500 Part I

Page 7 of 11 (REVISED 3/9/2017)

FAMILY CIRCUMSTANCES:

Do you have subsidized child care? □ Yes □ No

Does the child have a diagnosed disability with an IFSP? □ Yes □ No

Does the child have medical issues (prematurity, failure to thrive, spinal bifida, etc.)? □ Yes □ No

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

Do any of the following circumstances apply to your family (documentation is required)?

1. Documented Substance Abuse □ Yes □ No

2. Documented Domestic Violence □ Yes □ No

3. Documented DCF Referral and Court Order □ Yes □ No

4. Documented Working Parent □ Yes □ No

5. Documented Student (Official Transcripts) □ Yes □ No

6. Documented Incarcerated Parent □ Yes □ No

7. Documented Applicant for School Readiness Services □ Yes □ No

8. Documented Sibling of Returning Child(ren) □ Yes □ No

9. Documented Pregnant Woman □ Yes □ No

10. Documented Public Housing Resident □ Yes □ No

11. Documented Foreclosure (last 12 months/calendar year) □ Yes □ No

12. Documented Bankruptcy (last 12 months/calendar year) □ Yes □ No

13. Documented Unemployed (Compensation) □ Yes □ No

14. Documented Parental Disability □ Yes □ No

I certify that the information provided in this application package, and all supporting documentation is accurate and truthful. I

understand that providing false information or income omissions may be grounds for rejection of this application or termination of

childcare services. I will notify the agency immediately if there is any change to my contact information or family circumstances.

Parent/Guardian Signature: _____________________________________________________ Date: ______________

FORM

Early Head Start Enrollment Application 6500 Part I

Page 8 of 11 (REVISED 3/9/2017)

(Check upon receipt of documentation)

EARLY LEARNING COALITION OF MIAMI-DADE/MONROE

THE NEIGHBORHOOD PLACE FOR EARLY HEAD START

REGISTRATION REQUIREMENTS

Required Documents Collect at least one document from each area Yes No N/A

Proof of Age:

EHS- Birth to age 3 years

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 (2017).

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)

Support Documents Submit only if applicable Proof of Disability Individualized Family Support Plan (IFSP) Proof of Suspected Disability Doctor’s/Therapist’s Statement outlining concerns Proof of Homelessness Written Statement from Homeless Facility Proof of Substance Abuse Written Statement from Treatment Program Proof of Domestic Violence Written Statement from Domestic Violence Agency

Court Documentation (within the last year)

Proof of Student Status Current transcripts/schedule Proof of Active School Readiness Application Printout from Waitlist Proof of Parental Disability Written SSI recipient letter/Doctor’s statement Proof of Pregnancy Written Medical Documentation (current) Proof of Public Housing Residency MDPHA Written Rental/Lease Agreement Proof of Foster Caret/Legal Custody Documentation from Foster Care Agency/ Court Award Proof of Guardianship/Legal Custody Documentation from Court System/ Court Award

Parents certify that the information provided on the application and supporting documentation is true and correct; and that all sources of

income for parent(s)/legal guardian(s) has been reported. Deliberate misrepresentation of any information submitted may be subject to the

child being terminated from the program. Incomplete applications will not be accepted.

Parent’s Name: __________________________________________ Parent signature: ________________________________________ Date: __________

Staff Name: _________________________________________ Staff Signature: ________________________________________ Date: __________

FORM

Early Head Start Enrollment Application 6500 Part I

Page 9 of 11 (REVISED 3/9/2017)

Child’s Name: DOB:

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

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

W-2

TANF Documentation

Pay stubs or pay envelopes

Unemployment

ELC Verification of Income

ELC Work Calendar

Employer Letter

Foster care – Court Order

SSI Documentation

EHS Declaration of Income

Child Support

1099 – Misc.

Other If Other, please explain: ________________________

Relevant Time Period

Current Year

Previous 12 months

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

2. Staff signature: Date of eligibility verification:

3. Staff Name: Title: Family Support Specialist

4. Interview Conducted: Yes No In-Person Interview Telephone Interview

5. Staff signature: Date of interview:

Staff Name: Title: Family Advocate

6. Secondary Staff signature: Date of eligibility verification:

7. Secondary Staff Name: Danielle L. Campbell

Title: E.R.S.E.A. Manager

Enrollment Date: Entry Date:

2nd Year Entry Date: 3rd Year Entry Date:

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.

Eligibility Verification

Page 10 of 11

(REVISED 3/9/2017)

I hereby authorize the Early Learning Coalition of Miami-Dade/Monroe the Neighborhood Place for Early Head Start program to receive and release following information: School Readiness documentation, Physical examination, immunizations records (including a Tuberculosis Skin Test), dental examination and treatment plan, all assessment or diagnostic reports related to my child's health and development, and Individualized Family Service Plan (IFSP) from regional centers, Early Steps, Citrus Health Network, or other agencies (listed below):

All release of information about my child will follow the procedural safeguards outlined in the provisions of Federal and State Administrative Codes: Health Insurance Portability and Private Act (HIPAA), 2003; Family Educational Rights and Privacy Act (FERPA), 2009; Individuals with Disabilities Education Improvement Act (IDEA), 2004; and Head Start Performance Standards.

I understand this information is strictly confidential, will be used to provide necessary services, and permit statistical reporting on the results of screenings.

☐ Accept ☐ Decline

Parent/Guardian Signature:

Date:

Child Name: Child Date of Birth: Parent/Guardian Name:

Early Head Start Authorization to Release and Receive Information FORM

Part II 6561

Page 11 of 11

(REVISED 3/9/2017)

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.

Parent/Guardian’s Signature

Date

Child Name: Child Date of Birth: Parent/Guardian Name:

Name: □ Sibling □ Aunt/Uncle □Grandparent □ Other _________________

Address: City: State: Zip Code:

Phone: Cell

Landline

Alternate Phone: Cell

Landline

Name: □ Sibling □ Aunt/Uncle □Grandparent □ Other _________________

Address: City: State: Zip Code:

Phone: Cell

Landline

Alternate Phone: Cell

Landline

Name: □ Sibling □ Aunt/Uncle □Grandparent □ Other _________________

Address: City: State: Zip Code:

Phone: Cell

Landline

Alternate Phone: Cell

Landline

Name: □ Sibling □ Aunt/Uncle □Grandparent □ Other _________________

Address: City: State: Zip Code:

Phone: Cell

Landline

Alternate Phone: Cell

Landline

Name: □ Sibling □ Aunt/Uncle □Grandparent □ Other _________________

Address: City: State: Zip Code:

Phone: Cell

Landline

Alternate Phone: Cell

Landline

Name: □ Sibling □ Aunt/Uncle □Grandparent □ Other _________________

Address: City: State: Zip Code:

Phone: Cell

Landline

Alternate Phone: Cell

Landline

Name: □ Sibling □ Aunt/Uncle □Grandparent □ Other _________________

Address: City: State: Zip Code:

Phone: Cell

Landline

Alternate Phone: Cell

Landline

Early Head Start Emergency Contacts FORM

Part II 6564