HEAD START ENROLLMENT APPLICATION PLEASE READ …

1 HEAD START ENROLLMENT APPLICATION . PLEASE read before YOU BEGIN. INCA is an equal opportunity employer and service provider Dear Parents/Guardians, We are happy that you want to fill out an APPLICATION to INCA Head START Program. Enclosed in this packet, you will find the following forms: ENROLLMENT Information Child Health Record Nutrition Questionnaire/Assessment Family Service Assessment (This form is used to assess any needs your family may have.). Transportation Agreement & Emergency Contact Form Authorizations and Notifications (This form is used to confirm that you have read and understand our Child Abuse and Prevention Policy enclosed in this packet. It also gives us permission to use your child's photograph.)

2 PLEASE make sure to sign and initial where it indicates to do so. In addition to these forms, you will also be given a Dental Health Exam Form and a Physical Health Exam Form to give to your doctor and dentist. PLEASE return these to our office. Also, we MUST have a copy of the following in order to process your APPLICATION : Your APPLICATION will not be processed without proof of income and a birth certificate or other form of verifying your child's age. Proof of income Birth certificate Current Immunization Record Insurance Card (child's coverage). CDIB card (if applicable). PLEASE attempt to answer every question on these forms, as this information is important to our program.

3 If you have any questions or need any additional information, PLEASE do not hesitate to contact your local Family Advocate: Sandy Bonham: Murray County (Davis, Mill Creek, & Sulphur centers) 580-622-5700. Chuck Coulter: Marshall County (Kingston, Madill 3 & 4, Oakland centers) 580-677-9444. Sherri Adams: Johnston/Marshall County (Madill 1 & 2, Milburn, & Tishomingo centers) 580-371-2352. Teresa Workman: Atoka County (Atoka, Caney, & Wapanucka centers) 580-889-5193. 1. Applicant & Family Member Information Applicant (child applying for services) School District _____. Name: First Middle Last Nickname Address: Birthdate: ____M ____F. Race Hispanic English Proficiency Other Language Proficiency __Asian __Multi-Racial __Yes __Poor __Poor __Black __White __No __Little __Little __Hawaiian/Pacific Islander __Moderate __Moderate __American Indian/Alaska Native __ Proficient __ Proficient __Other_____.

4 Primary Health Coverage Insurance # Other Health Coverage Insurance #. Medicaid (Sooner Care) Medicaid # ____On Medicaid ____Not Eligible ____CDIB. ____ Yes ____ No ____Potentially Eligible Card # _____. Doctor Address City State Zip Phone Number Dentist Address City State Zip Phone Number Adult 1 (Primary). Name: First Middle Last Address: Birthdate: ____M ____F. Race Hispanic English Proficiency Other Language Proficiency __Asian __Multi-Racial ___Yes __Poor __Poor __Black __White ___No __Little __Little __Hawaiian/Pacific Islander __Moderate __Moderate __American Indian/Alaska Native __ Proficient __ Proficient __Other_____. Education Level Employment Child's Relationship Custody Check all that apply (adult 1).

5 __ GED __Full Time __Natural/Adopted/Step __Yes __Lives with Family __College __Part Time __Grandchild __No __Provides Financial Support __Degree Associate __Seasonal __Niece/Nephew __Teen Parent (currently). __Degree __High BA. School _S_tudent __Unemployed _Foster __Other If teen parent, subsidized? _ 8th _9th_10th _11th __ Retired __Yes __ No 2. Adult 2. Name: First Middle Last Address Birthdate: ____M ____F. Race Hispanic English Proficiency Other Language Proficiency __Asian __Multi-Racial __Yes __Poor __Poor __Black __White __No __Little __Little __Hawaiian/Pacific Islander __Moderate __Moderate __American Indian/Alaska Native __ Proficient __ Proficient __Other_____.

6 Education Level Employment Child's Relationship Custody Check all that apply (adult 2). __ GED __Full Time __Natural/Adopted/Step __Yes __Lives with Family __College __Part Time __Grandchild __No __Provides Financial Support __Degree Associate __Seasonal __Niece/Nephew __Teen Parent (currently). _DegreeSchool __High BA _S_tudent __Unemployed _Foster __Other If teen parent, subsidized? _ 8th _9th_10th _11th __ Retired __Yes __ No All Family Members in Household Last First Birthday Gender Child_____ _____ ____/____/___ ___M ___F. Child_____ _____ ____/____/___ ___M ___F. Child_____ _____ ____/____/___ ___M ___F. Child_____ _____ ____/____/___ ___M ___F. Child_____ _____ ____/____/___ ___M ___F.

7 Adult_____ _____ ____/____/___ ___M ___F. Adult_____ _____ ____/____/___ ___M ___F. Adult_____ _____ ____/____/___ ___M ___F. Adult_____ _____ ____/____/___ ___M ___F. Total number of Adults___ and Children___ in household, regardless of whether they are considered part of the family income eligibility purposes. How will your child get to school? _____. Parental Status Military Family Referred by DHS Receiving SNAP (Food Stamps). __One Parent __Yes __Yes __Yes __Two Parent __No __No __No 3. Family Information & Contacts Living Address: Zip City State County _____ _____ _____ _____ _____. Mailing Address :( if different) Zip City State County _____ _____ _____ _____ _____.

8 Phone Numbers Type (check one). ( )_____ __Cell __Home __Work __Other_____. ( )_____ __Cell __Home __Work __Other_____. ( )_____ __Cell __Home __Work __Other_____. Email Address_____. Emergency Contacts/Consenting Adults: INCA Is Authorized To Release My Child To: Contact 1 Name Relationship Emergency Contact Release To (pick up). _____ _____ __Yes __ No __Yes __ No Address Zip City State _____ _____ _____ _____. Phone #1 Phone #2 Phone # 3. ( ) _____ cell ( ) _____ home ( ) _____ work ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- -------------------- Contact 2 Name Relationship Emergency Contact Release To (pick up).

9 _____ _____ __Yes __ No __Yes __ No Address Zip City State _____ _____ _____ _____. Phone #1 Phone #2 Phone # 3. ( ) _____ cell ( ) _____ home ( ) _____ work ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- -------------------- Contact 3 Name Relationship Emergency Contact Release To (pick up). _____ _____ __Yes __ No __Yes __ No Address Zip City State _____ _____ _____ _____. Phone #1 Phone #2 Phone # 3. ( ) _____ cell ( ) _____ home ( ) _____ work ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- ---------------------------------------- -------------------- Restricted Persons: Is there anyone restricted from picking up or seeing your child?

10 ___ Yes ___ No Name:_____ Relationship to child_____. I give my consent for my child to be transported on the bus for field trips and in case of an emergency. Parent/Guardian Signature_____ Date_____. 4 Scan to CP Transportation Services Transportation Agreement Child's name_____. All applicants must understand and agree to the transportation agreement on this page. Transportation services may be arranged for children who cannot attend school without this assistance. PLEASE discuss your transportation needs with the Family Advocate. I agree: . To escort my child to the bus at the appropriate time. I understand that the bus is on a schedule and will wait one (1) minute for my child before continuing on the route.