Transcription of Head Start Enrollment Application
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Head Start Enrollment Application
CSA Head Start Enrollment ApplicationRevised 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 NameMILast NameBirth Date (mmddyyyy)Disabled (select one)Yes NoVeteran (select one)Yes NoIn the Military (select one)Yes NoMarital Status ((select one)MarriedLegally SeparatedSingleDivorcedWidowedGender (select one)MaleFemaleEthnicity (select one)HispanicNon-HispanicRace (select one)American Indian/Alaskan NativeAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhiteUnspecifiedOther:Primary Language (select one)EnglishSpanishOtherEnglish-Speaking Ability (select one)NonePoorWellVery WellMedical Insurance Coverage (mark all that apply)NoneMedicaidNevada Check UpIndian Health Services(IHS)PrivateMedicareVA/TricareOt herHighest Level of Education (select one)Grade 9 or LessHigh School Non-GraduateHigh School DiplomaGEDSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeCurrent Employment Status (mark all that apply)Full TimePart TimeSeasonally EmployedTrainingStudentUnemployedRetired or DisabledIf not currently employed, when was the last time the Primary Adult worked?)
CSA Head Start Enrollment Application. Revised 08/26/2014 **YOUR REQUEST CANNOT BE PROCESSED IF ANY FIELDS ON …
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