Head Start Application

JCCAC Head Start Application

Date
Child's Name:
Child's Physical Address:
Child's Mailing Address:
Phone:
Child's Social Security Number:
Date of Birth:
Sex:
School District:

Parent or Legal Guardian number 1 information:
Parent or Guardian's Name
Parent or Guardian's Social Security Number:
Parent or Guardian's Mailing Address:
Parent or Guardian's Phone:
Parent or Guardian's Highest Grade Completed:
Parent or Guardian's Employer Name:
Parent or Guardian's Work Number:

Parent or Legal Guardian number 2 information:
Parent or Guardian 2 Name:
Parent or Guardian 2 Social Security Number:
Parent or Guardian 2 Mailing Address:
Parent or Guardian 2 Phone:
Parent or Guardian 2 Highest Grade Completed:
Parent or Guardian 2 Employer:
Parent or Guardian 2 Work Number:
Please list all members of household with relationship to child:
Family Situation:
Custody:

Permission for Parent Roster:
I agree to have my name and telephone number included on the center's parent roster which will be made available upon request to any parent whose child is enrolled in the center.

Permission for Publicity: I agree to allow Head Start to use my child's name, photograph and artwork for videos, posting of pictures in the center, events, or publicity purposes, including the newspaper, radio and television.

Permission to give your family's name to agencies or organizations that provide Holiday assistance?

I need transportation to and from Head Start.

Please Note: Race and Ethnicity questions are used for statistical reporting purposes.
Child's Race/Ethnicity:
Mother's Race/Ethnicity:
Father's Race/Ethnicity:
Language
Does the Child's Family:
Is the housing:
What type of heat is in the home?
Smoke Detectors
Monthly house/rent payment
Does the family currently have transportation?
Form of transportation:
Is the Family TANF Eligible?
Sources of Income and Assistance: (Check all that apply)
Salary/Wages
 Self-employment
 Retirement/Pension/Vet
 OWF
 Unemployment
 Dividend/Interest
 Alimony/Support
 General Assistance
 Food Stamps
 SSI
 Housing
 Social Security
 Medical Assistance
 No Income
 Other
Does you or your spouse work:
Full Time
 Part Time
Are you or your spouse paid
Bi-Weekly
 Weekly
 Monthly
Your monthly gross income
Your spouse's monthly gross income

Assurance of confidentiality: The information on this form is being requested because of State or Federal law or local agency policy. All information is held in strict confidence.

I agree, and it is my intent, to sign this record/document electronically and submitting this record/document to the Jefferson County CAC, Inc. Head Start. I understand that my signing and submitting this record/document in this fashion is the legal equivalent of having placed my handwritten signature on the submitted record/document and this affirmation. I understand and agree that by electronically signing and submitting this record/document in this fashion I am affirming to the truth of the information contained therein.
Electronic Signature:
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