REQUIRED documents you must provide in order …

1 documents you must provide in order to process your application. REQUIRED1. Birth Certificate of the IF you're working, then provide a letter from your employer showing your working IF you're a Prenatal mom, then provide prenatal care documents . 6. Income Documentation such as: - Check Stub - W2 Form- Tax Return- TANF Letter- Child Support- Alimony Payments5. IF you're in college, then provide current class IF you're a Foster/Adoptive Parents, then provide court you a SINGLE Parent?NoYes(check one)What is the Secondary language at Home:What is the Primary language at Home:How many are CHILDREN ages 4 to 5 yrs?How many are CHILDREN ages 0 to 3 yrs?How many CHILDREN in your family?If YES then please explain:Has your child been identified by a PROFESSIONAL as having a disability or special need?YesNo(check one )YesNo(check one )Were you referred to our program (PACT)?If YES then by whom or what agency:YesDo you live with this child/applicant?

2 NoYes(check one)Do you support this child/applicant FINANCIALLY?NoYes(check one)What is your relationship to this child/applicant?(check one)Natural/Adopted/StepFosterOtherGuard ian(check one)Before, but not nowNoYesDo you receive Temporary Assistance for Needy Families (TANF) Money?How many other RELATIVES live in your home that you support FINANCIALLY?Section-BSection-BSection-BS ection-BFAMILY INFORMATIONNAME:DOB:What is your NATIONALITY?What is your ETHNICITY?Section-ASection-ASection-ASec tion-A( )Other( )Cell Phone:( )Work Phone( )Home Phone:Address:Address:MAILINGA ddress:City/State/Zip:City/State/Zip:HOM EA ddress:AsianWhiteHawaiian/Pacific IslanderBlackNative AmericanOtherRace (check ALL that apply)Highest grade in school COMPLETED?Grade 9 Grade 10 Grade 11 Grade 12 GEDSome College/Advance TrainingCollege Graduate/Training Certificate(check one)Employment Status now?Full-TimePart-Time Part-Time & TrainingRetired or DisabledUnemployed(check one)Full-Time & TrainingTraining or SchoolSeasonal EmployeePRIMARY ADULT or PRENATAL MOM: Information of the primary adult responsible for the : 1/2 Early Head Start/Head Start ApplicationParents And Children TogetherNAME:DOB:What is your NATIONALITY?

3 What is your ETHNICITY?Section-CSection-CSection-CSec tion-CAsianWhiteHawaiian/Pacific IslanderBlackNative AmericanOtherRace (check ALL that apply)Highest grade in school COMPLETED?(check one)Grade 9 Grade 10 Grade 11 Grade 12 GEDSome College/Advance TrainingCollege Graduate/Training CertificateEmployment Status now?Full-TimePart-Time Part-Time & TrainingRetired or DisabledUnemployed(check one)Full-Time & TrainingTraining or SchoolSeasonal EmployeeDo you live with this child/applicant?NoYes(check one)Do you support this child/applicant FINANCIALLY?(check one)What is your relationship to this child/applicant?(check one)Natural/Adopted/StepFosterOtherGuard ianSECONDARY ADULT: Information about the Secondary adult responsible for the : Information about the CHILD who is :DOB:What is your CHILD'S NATIONALITY?What is your CHILD'S ETHNICITY?AsianWhiteHawaiian/Pacific IslanderBlackNative American OtherRace (check ALL that apply)Is your child under MEDICAID for Health Insurance?

4 If YES then what is his/her MEDICAID Number?If YES then what is the name of his/her MEDICAID Coverage?Aloha Care QuestHMSA QuestKaiser QuestMed-QuestIs your Child under another Health Insurance?If YES then what is the Number?If YES then what is the Name?Other(check one )Who is the DOCTOR for this child/applicant?Who is the DENTIST for this child/applicant?Address:City:( )Phone:Name:Address:City:( )Phone:Name:INCOMEPLETEI certify that this information is true. If any part is false, my participation in PACT programs may be terminated and I may be subject to legal also understand that the information in this application will be held in strict confidence within the agency and is accessbile to me during normal business Signature:Date:Verifying Staff Member:Date:CERTIFICATION:Please read then sign and date your :NoYes(check one)NoYes(check one)NoYesWx | xw u ;e<Wx | xw u ;e<Wx | xw u ;e<Wx | xw u ;e<