Yes. Concerns expressed by: Medical Provider Primary care provider Social Service Agency Family Member Program Staff Other (Please Indicate): _

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~ Martin County Community Action, Inc. Head Start Program P.O. Box 806/415 E. Blvd. Suite 130

Williamston, NC 27892 (252) 789-4930 Fax: (252) 792-1838

DPlease bring proof of income, child's birth certificate, shot record, social security card, and medicaid card.

Child's Application

Parent Name: --- ^Date: ^_

Child's Name:

(First) (Last) (Middle)

Gender: Male Female

Date of Birth: --- ^SSN: ^_

Race: Black White __ Hispanic or Latino _ Other: (Please Indicate:

Language Spoken at Home: Primary: _

How well does your child speak English: __ Very Well Concerns about your child's overall health and development:

Describe concerns:

Secondary: _

Well Not Well Not atall

Yes No

Concerns expressed by: Medical Provider Primary care provider Social Service Agency

____ Family Member Program Staff Other (Please Indicate): _

Child iscared for by someone other than the parent:

___ Sibling under 12 __ Adult non-relative-not inhome Adult non-relative in home __ Sibling over 12

Other (Please Specify: _

Mailing Address: -::-- --:::-:----:-::-- ----: _

Street City/State Zip code

Relative Child Care Center Not yet arranged

Living Address: _

Street City/State

Cell Phone Number:

--- Zip code Home Phone:

Is your child enrolled inanother child care setting? __ Yes

If yes, name of program: _

No

FOR AGENCY USE ONLY

Program Applying For: Program Type: Status: Status Date:

Center: Class: Start Date: Income Eligibility Date:

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Name of Primary Parent/Guardian: Relationship to Child:

Person's role in the household: __ Mother/Mother Figure __ Father/Father Figure __ Legal Guardian __ Other (Please Indicate):

Date of Birth: _

Marital Status: __ Single

SSN: Gender: Male

Married __ Separated Divorced

White __ Hispanic or Latino __ Asian _ Other(Please Specify:

Race: Black

Language Spoken in Home: Primary:

How well does this person speak? English: __ Very Well Is this biological parent under age 17? _ Yes _ No Parent willing to pursue additional Education/Job Training?

Mailing Address:

Page 2

Female Widowed

Not Well

Secondary: _

Well Not at all

Yes No

Home Phone:

Occupation Status:

Paying Job:

_ Full Time (Over 30 hours aweek) Part Time

_ Seasonal- Agricultural _ Seasonal- Non-Agricultural

Work Phone:

--- --- Cell Phone:

Unemployed:

Homemaker Retired Disabled _Lost job

In School:

_ In school and employed _ High SchoollGED _ College Degree _ Graduate Degree

Business Certificate _ Other (Please Specify)

In SchoollPart Time

Highest Level of Education:

_ less than 8thgrade _ 9th-1

i

^h grade

_ lih grade (no diploma) _ no school completed

_ High School Grad GED

_ Some College (no degree) _ Certificate (college trade)

Job Training Program:

Yes No

_ Associates Degree _ Bachelor's Degree _ Master's Degree _ Doctorate Degree

Name of other Parent/Guardian living in the home (if applicable) --- Relationship toChild:

Date of Birth:

Marital Status: __ Single

Race: Black White

SSN: _ Gender: Male

Married __ Separated Divorced

__ Hispanic or Latino __ Asian _ Other(Please Specify: _ Widowed

Language Spoken in Home: Primary: Secondary:

How well does this person speak? English: __ Very Well _ Well __ Not Well Isthis biological parent under age 17? _ Yes _ No

Parent willing to pursue additional Education/Job Training? _Yes _ No

Mailing Address:

Female

Not atall

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Home Phone: --- Occupation Status:

Paying Job:

_ Full Time (Over 30 hours aweek) Part Time

_ Seasonal - Agricultural _ Seasonal- Non-Agricultural

Work Phone: --- Cell Phone: --- Unemployed:

Homemaker Retired Disabled _Lost job

Job Training Program:

Yes No

In School:

In School/Part Time

_ In school and employed _ High SchooIlGED _ College Degree _ Graduate Degree

Business Certificate _ Other (Please Specify) Highest Level of Education:

_ less than 8^th grade 9^th-12th (Trade

- I:>

_ lihgrade (nodiploma) _ no school completed

_ High School Grad GED

_ Some College (no degree) _ Certificate (college trade)

_ Associates Degree _ Bachelor's Degree _ Master's Degree _ Doctorate Degree

Family Type: (check one only) _ Two parent Family

_ Single Parent (Mother Only) _ Single Parent (Father Only)

_ Other Family Type: (Please Specify) _

_ Foster Family

_ Single (Living with Partner) Other Relatives

Housing (check one only) House

_Apartment

Mobile Home/Trailer

HotellMotel

_ Community Shelter _ Migrant Housing

Homeless

Other: _

Housing Payment: (check one only) Rent

Own

Section VIII

_Make nopayment _ Public Housing

_ Other (please specify) _

Services or financial Assistance received: (please check all apply)

No services received Start Date: End Date

Medical Assistance Child Support!Alimony

Energy Assistance

Food Stamps

Foster Care/Adoption

Public Assistance (WFF A,TANF) Public Housing

SSI/SS

Unemployment Insurance WIC

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Page 4

Length of time at current address: _less than 6 months _ 6-12 months _ 1-2years _ more than 2 years Number of moves in past 12 months __ Homeless in past 12 months__ Yes __ No

Length of time homeless: (months) Transportation:

Family has means of transportation? _ Yes _No Alternate means of transportation? _ Yes _No Check first box for primary and second box for alternate means of transportation:

Private Vehicle (car, truck, van)

Public Transportation (taxi, bus, transit, city bus) Relative/Friend's vehicle

School Bus

Other (please specify)

Family Referred from: _

Comments: ---

Please list all other children living in the household under 18:

Name Age Date of Birth Social Security # Relationship to Child

Please list all other adults living in the household:

Name Relationship to Child

Current Insurance Type:

Medicaid ID# ---

_ Private Insurance (Please complete below)

Insurance Provider Name: ---

NC Health Choice ID#

--- No Insurance

Policy Number: _

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Effective Date: ____________ Expiration Date: _ Primary Insurance? _ Yes _ No Has Dental Coverage _ Yes _ No

Current Medical Provider:

Phone Number #:

_____________ Date of last physical: _

Current Dental Provider:

Phone Number: #: ---

Date of last Exam:

---

Does your child receive any specialized services or is suspected of needing services such as speech,llanguage, physical or occupational therapy. If yes, please check the appropriate

Disability Evaluated by Suspected Identified Date

YeslNolNA YeslNolNA Autism

EmotionallBehavioral Disorder Health Impairmentlincl uding deafness

Learning Disability Mental Retardation Multiple Disabilities

Non-categorical/developmental delay

Orthopedic Impairment Speech/Language impairment Traumatic brain injury Visual Impairment, including blindness

Other:

MCCA, Inc Head Start Program supports the Office ofHead Start Fatherhood Initiative Program and your assistance is needed in getting your child's father/or positive male role model in their health and child

development. If the father lives outside the home, please provide the following information in order that we may contact him:

Name: ---

Address: ---

Telephone: Alternate Phone Number:

I certify that the information provided on this application is accurate and truthful to the best of my knowledge and is subject to verification. I am aware that I may be subject to termination from the program for false information.

Parent Guardian Printed Name:

Parent/Guardian Signature: Date:

---

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Page 6 Application submitted during the period of January through March for next school year will receive a letter indicating the child status by April 30^th• Applications submitted any other time during the year will receive notification within 30 days.

FOR AGENCY USE ONLY

Application Date:

Categorically Eligible:

Over Income Guidelines:

Child's Age:

Income Eligible: _

Income:

---

Diagnosed Disability: Suspected Disability (physical) _

Income Verification:

Individual Tax Form 1040 _ Public Assistance (TANF/WFFA) Letter

Foster Care Homeless W-2 Form Year_--- _Pay Stub