Head Start Enrollment Application

1 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))

2 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)

3 Full TimePart TimeSeasonally EmployedTrainingStudentUnemployedRetired or DisabledIf 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)YesNoHas 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)YesNoRelationship to Child Applying for Head Start (select one)Biological ParentStepparent by MarriageFoster ParentAdoptive/Legal GuardianGrandparentAunt or UncleOther.

4 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 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.)

5 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 Secondary Adult worked?

6 YesNoHas 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)YesNoRelationship to Child Applying for Head Start (select one)Biological ParentStepparent by MarriageFoster ParentAdoptive/Legal GuardianGrandparentAunt or UncleOther:Page 1 of 6 CSA Head Start Enrollment ApplicationRevised 08/26/2014 ENGLISH** your REQUEST CANNOT BE PROCESSED IF ANY FIELDS ON THIS Application ARE BLANK.**PRIMARY Adult's Information - Part 2 These questions are for the parent/guardian LIVING IN THE HOME who is the HEAD OF NameMILast NameWhat types of money did this person have in the LAST 12 MONTHS?

7 (MARK YES OR NO FOR ALL OF THE FOLLOWING)YesNoYesNoYesNoYesNoYesNoYesNo YesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNo YesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNo YesNoYesNoYesNoPay/Cash from Jobs, Work, Employment, or Self-EmploymentTraining StipendsUnemployment CompensationWorker's CompensationPension or RetirementSchool Grants or ScholarshipsFellowships or AssistantshipsNet RoyaltiesDividends or InterestRegular Insurance or Annuity PaymentsNet Rental IncomePeriodic Receipts from Estates or TrustsTemporary Assistance for Needy Families (TANF)

8 Cash AidSupplemental Secuirty Income (SSI) Cash AidSocial SecurityVeteran's BenefitsChild SupportSpousal Support or AlimonyFoster Care or Adoption SubsidyMilitary Family AllotmentsGeneral Assistance or General Relief Money PaymentsEmergency Assistance Money PaymentsGambling or Lottery WinningsRegular Cash or Help From Friends or FamilyExplain 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.

9 Did this person receive any UNDOCUMENTED pay or cash during the last 12 month? (select one)YesNoSECONDARY Adult's Information - Part 2 These questions are for the OTHER parent/guardian LIVING IN THE HOME who IS NOT the head of the NameMILast NameWhat types of money did this person have in the LAST 12 MONTHS? (MARK YES OR NO FOR ALL OF THE FOLLOWING)YesNoYesNoYesNoYesNoYesNoYesNo YesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNo YesNoYesNoYesNoYesNoYesNoYesNoYesNoYesNo YesNoYesNoYesNoPay/Cash from Jobs, Work, Employment, or Self-EmploymentTraining StipendsUnemployment CompensationWorker's CompensationPension or RetirementSchool Grants or ScholarshipsFellowships or AssistantshipsNet RoyaltiesDividends or InterestRegular Insurance or Annuity PaymentsNet Rental IncomePeriodic Receipts from Estates or TrustsTemporary Assistance for Needy Families (TANF)

10 Cash AidSupplemental Secuirty Income (SSI) Cash AidSocial SecurityVeteran's BenefitsChild SupportSpousal Support or AlimonyFoster Care or Adoption SubsidyMilitary Family AllotmentsGeneral Assistance or General Relief Money PaymentsEmergency Assistance Money PaymentsGambling or Lottery WinningsRegular Cash or Help From Friends or FamilyExplain 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.