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)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?)

2 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: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.)

3 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?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.

4 **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? (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) 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.

5 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)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) 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.

6 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)YesNoPage 2 of 6 CSA Head Start Enrollment ApplicationRevised 08/26/2014 ENGLISH**YOUR REQUEST CANNOT BE PROCESSED IF ANY FIELDS ON THIS Application ARE BLANK.**Family Information All questions in this section pertain to the family applying for the CSA Head Start Program. Living AddressUnit/SpaceCityStateZip CodeMailing AddressUnit/SpaceCityStateZip CodePrimary Phone (9999999999)HomeCellWorkMessageSecondary Phone (9999999999)HomeCellWorkMessageAdditiona l Phone (9999999999)HomeCellWorkMessageEmail AddressWhat is your family's current housing situation? (select one)RentOwnHomelessExplain Other:Is your family living in someone else's home?

7 (select one)YesNoAre you making any payments for housing or any payments for utilities? (select one)YesNoWhat type of dwelling does your family live in? (select one)ApartmentSingle-family HouseCondo/TownhouseDuplex/Triplex/4-ple xMobile Home or TrailerMotel or HotelShelterPark, Street, Car or CampsiteWhat is your family's current transportation situation? (select one)CarFriend's or Relative's CarPublic TransportationNo TransportationIs your family receiving any of the following services? (mark all that apply)WICFood Stamps/SNAPE nergy Assistance Program (EAP)Section 8 HousingHUD Housing AssistanceNo services are being receivedIn addition to enrolling your child in Head Start , please indicate your top four (4) needs (mark up to 4)FoodHousingClothingMedicalTransportati onJob Training or PlacementEnergy or Utility AssistanceTax Return AssistanceExplain Other:How did you hear about Head Start ? (select one)CSA Head Start Flyer by Postal MailPhone BookInternet WebsiteRadioTelevisionFamilyFriendOutsid e Agency ReferralNewspaperCommunity EventsCSA Head Start Poster/FlyerCSA/Head Start Internal ReferralPlease specify your family type (select one)Two-parent FamilyMother Figure Only/Single-parent FamilyFather Figure Only/Single-parent FamilyGrandparents Raising GrandchildrenFoster FamilyOther Relatives/PersonsMotherHow many people are living in the home?

8 (write a number next to each) For example- Mother: 1 Father: 1 Other Adults: 1 Your children: 3 Other Children: 1 FatherOther AdultsYour ChildrenOther 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.

9 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 '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 3 of 6 Agency Name:CSA Head Start Enrollment ApplicationRevised 08/26/2014 ENGLISH**YOUR REQUEST CANNOT BE PROCESSED IF ANY FIELDS ON THIS Application ARE BLANK.**Has child support or cash been received for this child in the last 12 months?

10 (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 NameMI Last NameBirth Date (mmddyyyy)Disabled (select one)Yes NoYes NoGender (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)PrivateOtherIf you selected Medicaid, what plan does this child Have?