Salt River Pima-Maricopa Indian Community Early Childhood Education Programs Mailing Address: 10, 005 E. Osborn Road
Physical Address: 4815 N. Center Street Scottsdale, AZ 85256
Phone: 480-362-2200 |Fax: 480-362-2201
Thank you for applying to the Salt River Early Childhood Education Center. Submit this completed application along with the required documents to the Enrollment office and your child’s eligibility will be determined. If your child is selected for enrollment, you will be notified by mail and/or phone. If there are no vacancies, your child will be placed on the waiting list.
Program options include:
Infant Toddler: serving pregnant women > 2 years old School hours: 9:00 a.m. – 1:00 p.m.
Child must live in the SRPMIC Home-based option available
Before/After School program requirements:
Child must be enrolled in a federally recognized tribe
Parents/guardians must be working or in school/job training full time (working requirement is waived for children in protective care)
Parents may not have an outstanding bill at ECEC Fees are based on family size/income level
Parent co-payment required (fees waived for children in protective care) Preschool: serving 3 and 4 year olds
School hours: 9:00 a.m. – 1:00 p.m.
Child must live in SRPMIC – OR – be enrolled in the SRPMIC (Tribal Preschool only)
Before/After School program: Hours: 7:00 a.m. – 6:00 p.m. (child must attend 9:00 a.m. – 1:00 p.m.) Child must be enrolled in a federally recognized tribe
Child must live in Mesa, Tempe, Scottsdale, or Phoenix (including SRPMIC)
Parents/guardians must be working or in school/job training full time (working requirement is waived for children in protective care)
Parents may not have an outstanding bill at ECEC Fees are based on family size/income level
Parent co-payment required (fees waived for children in protective care)
Submit the following documents with this completed application: REQUIRED: Proof of Income
o Last two consecutive paycheck stubs, proof of per capita income, lease income, SSI, court order child support/spousal maintenance, unemployment compensation, grant/loan statement, regular insurance or annuity payments, TANF benefit statement
o Written verification of employment must be submitted for those who are self-employed, have not yet received paychecks, or receive payment in cash
REQUIRED: School or job training schedule (if using school status for Before/After School program eligibility)
REQUIRED: Child’s tribal ID (for Before/After School program) REQUIRED: Court order/Custody papers if applicable
Child’s birth certificate Current immunization record
Select Program Option: [ ] ECEC { } Regular school hours: 9:00 a.m. – 1:00 p.m.
{ } Before/After school hours: 7:00 a.m. – 6:00 p.m. (Must attend 9:00 a.m.-1:00 p.m.) [ ] Home-based (children under 3 years old and pregnant women living in the SRPMIC only)
[ ] Eagle’s Nest (for Salt River High School/ALA students only) SECTION 1 – APPLICANT INFORMATION (PLEASE PRINT)
CHILD’S NAME ( Last, First and Middle) BIRTHDATE ( MM/DD/YYYY) GENDER
Male Female
TRIBAL AFFILIATION TRIBAL ENROLLMENT NUMBER RACE
Native American/Alaska Native Native Hawaiian or Pacific Islander White Asian Biracial/Multi-Racial Black/African American
ETHNICITY
Hispanic-Latino Origin Non-Hispanic-Latino Origin
MAILING ADDRESS CITY, STATE, ZIP CODE
RESIDENTIAL DIRECTION/DESCRIPTION OF HOME
Parent/Guardian’s information (those with custodial/legal rights to the child only)
PARENT/ GUARDIAN NAME RELATIONSHIP TO CHILD Lives with child? Yes No
RACE/ETHNICITY TRIBAL AFFILIATION & ENROLLMENT NUMBER
ADDRESS CITY, STATE, ZIP CODE
HOME NUMBER WORK PHONE NUMBER
CELL NUMBER EMAIL ADDRESS (OPTIONAL)
HIGHEST LEVEL OF EDUCATION COMPLETED
Less than HS Current HS Student /GED HS Graduate Some College Associates Bachelors Higher
OCCUPATION
ATTEND SCHOOL/ TRAINING
FULL TIME PART TIME NO SCHOOL
EMPLOYED
FULL TIME PART TIME UNEMPLOYED EMPLOYER/SCHOOL NAME EMPLOYER/SCHOOL ADDRESS(Number, Street, City, State, Zip
Code)
FAMILY COMPOSITION: TEEN PARENT SINGLE PARENT TWO PARENT PREGNANT
Due Date: Trimester: 1st 2nd 3rd Diagnosed as high risk? Yes No
RELATIONSHIP STATUS:
Parent/Guardian’s information (those with custodial/legal rights to the child only)
PARENT/ GUARDIAN NAME RELATIONSHIP TO CHILD Lives with child? Yes No
RACE/ETHNICITY TRIBAL AFFILIATION & ENROLLMENT NUMBER
ADDRESS CITY, STATE, ZIP CODE
HOME NUMBER WORK PHONE NUMBER
CELL NUMBER EMAIL ADDRESS (OPTIONAL)
HIGHEST LEVEL OF EDUCATION COMPLETED
Less than HS Current HS Student /GED HS Graduate Some College Associates Bachelors Higher
OCCUPATION
ATTEND SCHOOL/ TRAINING
FULL TIME PART TIME NO SCHOOL
EMPLOYED
FULL TIME PART TIME UNEMPLOYED EMPLOYER/SCHOOL NAME EMPLOYER/SCHOOL ADDRESS (Number, Street, City, State, Zip
Code)
FAMILY COMPOSITION: TEEN PARENT SINGLE PARENT TWO PARENT RELATIONSHIP STATUS:
MARRIED SEPARATED DIVORCED LIVE-IN RELATIONSHIP SINGLE List Family Members who are supported by your income:
NAME AGE DOB RELATIONSHIP To Parent/Guardian
SECTION 2-ABOUT YOUR CHILD
IS YOUR CHILD TRANSFERRING FROM ANOTHER HEAD START OR CHILD FIND PROGRAM?
Yes No (If yes, where )
IS CHILD CURRENTLY IN FOSTER CARE?
Yes No (if yes, please provide letter of placement)
Case Worker’s Name & Phone:
DOES YOUR CHILD HAVE A DIAGNOSED DISABILITY? Yes No IF SO, IS SHE/HE ON AN IEP OR IFSP? Yes No
THIS STATEMENT WILL BE USED TO DETERMINE WHETHER YOUR CHILD WILL BE ASSESSED FOR ENGLISH LANGUAGE PROFICIENCY
Primary language of family at home?
DO YOU HAVE ANY CONCERNS ABOUT YOUR CHILD’S
Speech? Yes No Not Sure Vision? Yes No Not Sure
Behaviors? Yes No Not Sure Hearing? Yes No Not Sure Development? Yes No Not Sure Height/Weight? Yes No Not Sure Does your child receive early intervention services, special education, speech, physical therapy, or occupational therapy? Yes No
Service Provider Name: Telephone Number:
Was your child born prematurely? Yes No If yes, at how many weeks:
Is your family currently receiving services from any community agency (child abuse/neglect,
alcohol/substance abuse, domestic violence, homelessness, incarcerated parent, etc.) Yes No If yes, describe:
Are one or both parents/guardians of child on active duty in the U.S. military? Yes No IS YOUR CHILD OR ANY FAMILY MEMBER RECEIVING?
WIC Yes No SOCIAL SECURITY INSURANCE Yes No
LEARN
(Cash Assistance Only) Yes No FOOD STAMPS Yes No
DES Child Care
Assistance Yes No IS YOUR FAMILY HOMELESS? Yes No
WHAT TYPE OF HEALTH INSURANCE DOES YOUR CHILD HAVE?
Private Insurance AHCCCS/Medicaid KIDS CARE No Insurance WHERE DOES YOUR CHILD RECEIVE MEDICAL AND DENTAL CARE?
Private Doctor Private Dentist Urgent Care/Emergency Room
SECTION 3-INCOME
I RECEIVE INCOME FROM THE FOLLOWING SOURCES AT THIS TIME (CHECK ALL THAT APPLY) Wages from Employment
(inc., commission, tips, bonus) Child Support/Spousal Maintenance (Alimony) Public Assistance (TANF/Cash Assistance) Income from Land or Rental Property Scholarships or Educational Training
Stipends or Grants
Supplemental Security Income (SSI) or Death Benefits, annuities, retirement funds, land lease
Unemployment Compensation Per Capita (Non-SRPMIC)
SRPMIC Per Capita: (amount will be calculated per quarterly distribution per Finance office) One household member Two household members
Zero Income – I currently have zero income – If you have zero income, you must submit a Zero Income statement.
Self-Employed – If you are self-employed you must submit a notarized self-employment form.
SECTION 4-DECLARATION AND CONSENT
I understand that I/we have completed this application and declare that all the information provided on the ECEC application, to the best of my knowledge, is true and accurate. If any information provided on the application is found to be falsified, I/we understand that my application will not be considered for selection and will be withdrawn.
PARENT/GUARDIAN SIGNATURE PRINT NAME DATE
PARENT/GUARDIAN SIGNATURE PRINT NAME DATE
