Section 1: Eligible Child Information
Required Fields (*)
* Child's Full Legal Name: (First, Middle, Last)  
* Date of Birth: Gender:
Ethnicity:
Race:




If Other specify:
      
Child/Family’s Primary Language: If Other specify:
English as Second Language:   

Does this child have Health Insurance?

(Type)
Does this child have Dental Insurance?

(Type)
Doctor's Name: Dentist's Name:

Does this child have a health concern or disability/special needs?


Does this child have a current IEP or IFSP?
    
Is there a Court Order limiting or restricting custody and/or access to the child?
* If there is a Court Order, please provide a certified, current copy of the order to Head Start *
Is this household:
Household family size:
Total number of children:
Total number of adults:
Is your family experiencing homelessness (lack of a fixed, regular/adequate nighttime residence, Community Shelter)
Section 2: Parent/Guardian 1 - Information
     
* Name (First, Middle, Last): Date of Birth:
Relationship: If other, specify: Residence in home:
Ethnicity:
Race:




If Other specify:

 
* Primary Phone: Alternate Phone:
* Address:  
*City: *Zip code:
*What school district does your family reside in?    
       
Education Level
(select highest completed):




 
Are you currently in school/training?


 
Are you currently working? Yes (Choose below)


No (Choose below)



   
Are you a veteran of the United States military?

 
Are you a member of the United States military on active duty?

 
Do you currently have Health insurance for yourself?
If yes, specify:

 
Section 3: Parent/Guardian 2 - Information  
     
Name (First, Middle, Last): Date of Birth:
Relationship: If other, specify: Residence in home:
Ethnicity:
Race:




If Other specify:
 
      
Primary Phone: Alternate Phone:
Address:  
City: Zip code:
What school district does your family reside in?    
       
Education Level
(select highest completed):




 
Are you currently in school/training?


 
Are you currently working? Yes (Choose below)


No (Choose below)



   
Are you a veteran of the United States military?

 
Are you a member of the United States military on active duty?

 
Do you currently have Health insurance for yourself?
If yes, specify:
 
      
*Section 4: Program Options
    



    
Section 5: Other Household Members - include ALL children and adults in the household EXCEPT Parent/Guardian(s)
     
1. Name (First, Middle, Last): Date of Birth:
Gender: Relationship to Child:
Ethnicity:
Race:




If Other specify:
 
Health Insurance: If yes, specify:

2. Name (First, Middle, Last): Date of Birth:
Gender: Relationship to Child:
Ethnicity:
Race:




If Other specify:
 
Health Insurance: If yes, specify:

3. Name (First, Middle, Last): Date of Birth:
Gender: Relationship to Child:
Ethnicity:
Race:




If Other specify:
 
Health Insurance: If yes, specify:

4. Name (First, Middle, Last): Date of Birth:
Gender: Relationship to Child:
Ethnicity:
Race:




If Other specify:
 
Health Insurance: If yes, specify:

5. Name (First, Middle, Last): Date of Birth:
Gender: Relationship to Child:
Ethnicity:
Race:




If Other specify:
 
Health Insurance: If yes, specify:

6. Name (First, Middle, Last): Date of Birth:
Gender: Relationship to Child:
Ethnicity:
Race:




If Other specify:
 
Health Insurance: If yes, specify:
     
*Section 6: Income Eligibility

How is my family eligible?
Someone in the household is:






Size of Family Annual Income
(100%)          (130%)
Size of Family Annual Income
(100%)        (130%)
1 $12,060 $15,678 5 $28,780 $37,414
2 $16,240 $21,112 6 $32,960 $42,848
3 $20,420 $26,546 7 $37,140 $48,282
4 $24,600 $31,980 8 $41,320 $53,716
    
*Section 7: Household Monthly Family Income
Employment: $  /Month
Social Security Disability (SSD): $  /Month
Child Support: $  /Month
Spousal Support/Alimony: $  /Month
Unemployment: $  /Month
Other: $  /Month
* PROOF OF INCOME (12 MONTHS PRIOR TO APPLICATION DATE), PROOF OF CASH ASSISTANCE, SSI DOCUMENTATION OR FOSTER PLACEMENT LETTER MUST BE SUBMITTED ALONG WITH THE APPLICATION TO BE CONSIDERED FOR THE PROGRAM *
(ANY AND ALL DOCUMENTS SENT WILL BE KEPT CONFIDENTIAL)

Upload proof of income:


Is your family receiving any of these services or experiencing any of the following?













How did your family hear about Head Start?















I declare under penalty of perjury and the laws of the state of Pennsylvania that the information and income contained herein is true and correct to the best of my knowledge. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.
        
* Parent/Guardian Signature:
(Please type full name)
Date: 11/23/2017