PLEASE KEEP THIS LETTER FOR YOUR INFORMATION

1 KI BOIS COMMUNITY ACTION FOUNDATION INC. Box 727 200 Southeast A Street Stigler, OK 74462-0727 PHONE: TOLL FREE: FAX: BOARD CHAIRPERSON Gene Bass EXECUTIVE DIRECTOR/CEO R. CARROLL HUGGINS, CCAP PLEASE KEEP THIS LETTER FOR YOUR INFORMATION Dear Parent or Guardian: Thank you for completing the enrollment application for the KI BOIS head start /Early head start Program. Your child will be prioritized according to family size, income, age, and disability (if any). Foster children, homeless families and those receiving TANF and/or SSI are automatically eligible. To be considered as having a disability, the child must have been diagnosed by a professional and written documentation must be attached to the child s application.

2 Federal regulations state that we may enroll 10% of our children from families who are above income guidelines. We are sorry that we cannot serve all children. State regulations require all children participating in the program be up-to-date on immunizations before entering the program (see chart on back for more details). head start /Early head start children are required to receive a dental exam and a well-child check-up, which includes: measurements, sensory screenings, developmental screening, physical exam and blood work. head start also requires documentation of your child receiving at least one lead screen. If your child is selected to attend head start /Early head start and your family has barriers that prevent you from getting medical or dental care PLEASE discuss this with head start /Early head start staff at your center so they can help develop a plan to get your child connected to a medical and dental home.

3 PLEASE note that as part of the enrollment process, you will have an interview with a head start /Early head start staff person. DOCUMENTS YOU WILL NEED (Copies only, these will not be returned) Income Verification The documents needed to show your income. (All that apply) Proof of Temporary Assistance to Needy Families (TANF) (if applicable) Proof of Supplemental Security Income (SSI) (if applicable) Homeless verification (if applicable) Pay stubs or employer statement Tax return 1040 (adjusted gross) or W2 Social Security/Disability (if applicable) Statement of no job or income (if applicable) Child support (if applicable) Any other income source not listed Birth certificate or other proof Proof of legal custody (if the child is in foster care or if you are the child s legal guardian) Immunization record Disability documentation (if applicable) Well-child check-up and dental exam documentation (if available)

4 Documentation of pregnancy/due date When you have gathered your documents and completed your application PLEASE bring them to a location near you. If you have any questions about the application process, PLEASE ask the head start /Early head start staff for help or call toll free 1-800-299-4479. Age Vaccine Birth 1 Month 2 Months 4 Months 6 Months 12 Months 15 Months 18 Months 2 Years 4-6 Years HepB Dose 1 Dose 2 Dose 3 DTaP Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Hib Dose 1 Dose 2 Dose 3* Dose 3 or 4* PCV Dose 1 Dose 2 Dose 3 Dose 4 Polio Dose 1 Dose 2 Dose 3 Dose 4 MMR Dose 1 Dose 2 Varicella Dose 1 Dose 2 HepA Dose 1 Dose 2 Agency Use Only HS Priority # EHS Priority # PS Only Not-Eligible head start : 3 and 4 year olds CENTER:_____ Early head start : 6 weeks to 3 year old.

5 Pregnant women CENTER: Sallisaw EHS CHILD S INFORMATION Child s Legal Name: First Middle Last Child s Date of Birth Gender: Male Female Social Security # Family Size: Child s Ethnicity Child s Race Child s Primary Language Non-Hispanic or Latino Hispanic or Latino American Indian Black Asian White Other ( PLEASE specify)_____ English Parent will need interpreter Spanish Child will need interpreter Other ( PLEASE specify)_____ Mailing Address: City: Zip: Street Address or Finding Directions: Home Phone: Cell Phone: Email: Has child attended head start previously? Yes No If so, When? Where?

6 Does child have a disability? Yes No If yes, what is it? Has disability been diagnosed by a professional? Yes No If yes, PLEASE attach documentation. FAMILY INFORMATION Parent/Guardian: Parent/Guardian: Social Security #: Social Security #: Employed by: Employed by: With whom does child live?_____ If not parent, are you the legal guardian Yes No If yes, guardianship documentation must be attached. List all children in the household: Is anyone in the household pregnant? Yes No If yes, what is the expected due date? INCOME Does anyone in your household receive any of the following? If yes, documentation must be attached. Temporary Aid to Needy Families (TANF) Yes No Supplemental Security Income (SSI) Yes No Is your family living in a shelter, hotel, vehicle or with a friend or relative?

7 Yes No Foster child? Yes No All others must attach income of parent(s) or guardian of the child enrolling in the program. PLEASE specify the amount and how often the income you are reporting is received. Proof of Income by: Parent/Guardian Parent/Guardian Income Tax Form 1040 Social Security W-2 Form Unemployment Pay Stub Employer Statement Child Support Other (Specify) Total Yearly Income for Family: KI BOIS head start enrollment APPLICATION RECRUITMENT SURVEY Check which program you are applying for: AN INCOMPLETE APPLICATION WILL DELAY enrollment . Will you provide transportation for your child to and from head start ? Yes No If not, how will your child get to and from head start ?

8 Is your child receiving any of the following benefits? Sooner Care Benefits: Indian Health Benefits: TANF: Family Health Insurance: Card# Chart# TANF# Name of Company Will you be applying for Sooner Care Health insurance for you/your child? Yes No Not Applicable If you need INFORMATION about these services, PLEASE ask KI BOIS staff. Do you currently have a child enrolled in head start ? Yes No If so, where? Early head start Only: PLEASE check any that apply to your family Mother (13-16 yrs.) Parent with less than high school education Mother (17-21 yrs.) Dual Language Family Mother (22-34 yrs.)

9 Incarcerated Parent Mother (over 35 yrs.) Child has Diagnosed Disabilities with IFSP Single parent/guardian Child has Suspected Disabilities Guardian/Caretaker other than parent SoonerStart/Health Professional Recommendation Disabled Parent/Guardian PLEASE make sure that all questions are answered completely. This form will become a permanent part of your child s head start enrollment if accepted into the program. I certify that the INFORMATION stated in this application is true and correct to be best of my knowledge.

10 Signature of parent/guardian: Date TO BE COMPLETED BY STAFF Documents Verified and attached (select as many as apply): Birth Certificate or other proof Immunization record Income tax form 1040 Social Security Check Stub W2 Employer Statement Unemployment Statement of no income Child Support Other_____ TANF SSI Homeless statement Foster Child documentation Disability documentation Guardianship documentation Well-child check-up and dental exams Pregnancy documentation Verifying staff member signature: Date In-person Interview Phone Interview: Provide reason for phone interview in lieu of in-person interview. Additional Comments: AN INCOMPLETE APPLICATION WILL DELAY enrollment .