PMS Head Start Application

Head Start Application

Thank you for taking the time to complete the following application.
Please note that after your application is reviewed, we will require specific documentation before an approval decision can be made. This documentation includes the following:

1. Proof of all income from the previous year or 12 months from the date you turn in your application. Examples include: most recent income tax form 1040A or 1040 and W-2 forms; pay stubs or written statement for all jobs; documentation of TANF, SNAP, SSI or homelessness; documentation of child support.

2. Child's original Birth Certificate or Baptismal Record

3. Marriage License and/or Divorce Decree (for Little Feet location only)

4. Child Immunization Record or State Exemption Form

5. Child's Certificate of Indian Blood (CIB), if applicable.

6. Current Medicaid or Insurance Card.

7. If your child has a diagnosed disability, please submit copies of your child's most recent IEP IFSP records from the Special Education Program providing services (we can assist you in obtaining these records with your written authorization).

8. For children who are in Protective Custody or who are living with Foster Parents, please submit court documentation of this placement.

9. Court documentation (restraining orders, custody arrangements, parenting plans, etc.)
SECTION 1: APPLICANT INFORMATION
How did you hear about Head Start/Early Head Start?
Child’s Name:*
Date of Birth:

MonthDayYear
MaleFemale
Parent/Guardian’s Name:*

First NameLast Name
Home Phone:*
Please enter a valid phone number.
Cell:
Please enter a valid phone number.
Email:
example@example.com
Parent/Guardian’s Name:

First NameLast Name
Home Phone:
Please enter a valid phone number.
Cell:
Please enter a valid phone number.
Email:
example@example.com
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Living Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Child’s Race:

WhiteAmerican Indian Tribal Affiliation/Census #African American/BlackAsianNative Hawaiian or Other Pacific IslanderBi-racial
Child’s Ethnicity:

Hispanic or Latino or Spanish OriginNot Hispanic or Latino or Spanish Origin
Language:
What language is spoken the most in your home?
Does your child speak English?

Very WellWellNot WellNot at all
Does your child speak any other language?
SECTION 2: DISABILITIES INFORMATION
Has your child been diagnosed with, or suspected of having, a disability or developmental delay?

YesNo
If yes, please list:
Date of Evaluation:

MonthDayYear
At risk for developmental delay due to biological, medical, or environmental factors?

YesNo
Complications at Birth:

Low birth weightPrematurePrenatal exposure to drugs, medications, etc. known to be associated with developmental delay.
Who Completed Evaluation:
Does your child require any medical accommodations?

YesNo
Does your child take any medications?

YesNo
If yes, please specify:
Is your child on a special diet or have allergies to any foods?

YesNo
If yes, please specify:
Any Behavioral Concerns:

YesNo
If yes, please specify:
SECTION 3: FAMILY INFORMATION

Indicate Family Type:
Two Parent FamilySingle Parent Family
If Single Parent Family: The Child lives with

MotherFather
Other Relative(s): Specify:
Foster Family
Other Family Type Specify:
Living Together

Please list below everyone living in your household beginning with the Head of Household:

	Name	DOB	Relationship to Child	Language	Employed PT/FT	School PT/FT	Office Use Only √ if Not financially Responsible for Child
1
2
3
4
5
6
7
8

Number of Adults:
Number of Children:
SECTION 4: EDUCATION/EMPLOYMENT INFORMATION
Mother/Guardian’s Name:
DOB:

MonthDayYear
Date
Race:

Bi-RacialWhiteAmerican Indian or Alaskan NativeHawaiian or Other Pacific IslanderAsianBlack or African American
Ethnicity:

Hispanic or Spanish OriginNot Hispanic or Spanish Origin
Marital Status:

singlemarrieddivorcedliving with partner
Language:
What language is spoken?
Do you speak any other language(s)?
Employment:
Employed Hours per Week
Full Time (28+ hours)Part TimeSeasonalTemp.Parent is Incarcerated
Employer:
Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.
Education
Highest Grade Completed:

No school completedHigh School GraduateGED9th Grade10th Grade11th Grade12th Grade (no diploma)Some College (no degree)Associate’s DegreeBachelor’s DegreeGraduate DegreeOther
Completion Date:

MonthDayYear
Date
Student?

YesNo
Full Time (12+hours)Part Time (less than 12 credit hours)Other
Field of Study:
School:
Father/Guardian’s Name:
DOB:

MonthDayYear
Date
Race:

Bi-RacialWhiteAmerican Indian or Alaskan NativeHawaiian or Other Pacific IslanderAsianBlack or African American
Ethnicity:

Hispanic or Spanish OriginNot Hispanic or Spanish Origin
Marital Status:

singlemarrieddivorcedliving with partner
Language:
What language is spoken?
Do you speak any other language(s)?
Employment:
Employed Hours per Week
Full Time (28+ hours)Part TimeSeasonalTemp.Parent is Incarcerated
Employer:
Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Please enter a valid phone number.
Education
Highest Grade Completed:

No school completedHigh School GraduateGED9th Grade10th Grade11th Grade12th Grade (no diploma)Some College (no degree)Associate’s DegreeBachelor’s DegreeGraduate DegreeOther
Completion Date:

MonthDayYear
Date
Student?

YesNo
Full Time (12+hours)Part Time (less than 12 credit hours)Other
Field of Study:
School:
SECTION 5: CHILD CARE INFORMATION

If applicable, who cares for your child when you are at work or school?
Childcare centerChildcare homeRelative or other adult in your homeRelative or other adult in their homeDoes not applyOther
Childcare center, please specify:
Childcare home, please specify:
How is the child care paid for:

Self-PayFull PriceSliding ScaleCo-PayAssistance
Specify Source of Assistance
Do you need child care year-round?

YESNO
Why?
If you know, please indicate what Head Start/Early Head Start location you would like your child to attend.
SECTION 6: HOUSING INFORMATION
Type of Housing:

Mobile HomeHouseApartmentOther
Do you:

RentOwnOther
Length of time at current address:
Number of times family has moved in the past 12 months:
Have you been homeless in the past 12 months:

YesNo
SECTION 7: TRANSPORTATION INFORMATION
Do you have access to a vehicle:

YesNo
SECTION 8: PROGRAM INFORMATION
Early Head Start (0 to 36 months)Head Start (3 to 5 years)
FOR EHS ONLY:
My preference is:

Full Day, Year Round (times vary)Home Based Services
Explain Why:
SECTION 9: FAMILY ASSISTANCE INFORMATION
What Services or Assistance Are You Currently Receiving?

NM Works (TANF)Unemployment InsuranceSSDI –Disabilities/Survivor’sHUDSNAP (Nutrition Assistance Program)WIC/ECHOMedicaidSSI (Supplemental Security Income)None of The AboveOther
Family Issues:

Chronic Health ProblemsParents with DisabilitiesParent is IncarceratedHomelessnessPhysical IsolationSubstandard HousingNo TransportationViolence in the Home
What Services Do You Need?

NM Works (TANF)WIC/ECHOMedicaidUnemployment InsuranceSSDI- Disabilities/Survivor’sHUDSNAP (Nutrition Assistance Program)None of the AboveOther
Emergency Assistance Needed:

FoodHousingUtilitiesClothingHealth Care
SECTION 10: EXPECTANT WOMAN INFORMATION FOR PREGNANT WOMEN ONLY
Would you be interested in our prenatal home-based program?

YesNo
What is your current month of pregnancy?
What is the expected due date?
SECTION 11: SIGNATURES
To the best of my knowledge, all information provided in this application is true and correct.

Clear
Date

MonthDayYear
Date
For OfficeUse Only
Application Completed (initial)
Selected

YesNo
Date Selected

MonthDayYear
Date
# Household
Criteria Weight
Over Income by $
Income Eligible
Child Age
Income Approved?

YesNo
If over income approved, give reason
Authorized Personnel
Authorized Personnel
Authorized Personnel
COUNTY:
SCHOOL DISTRICT:
SITE:
PROGRAM:
APPLICATION DATE:

MonthDayYear
SITE PREFERENCE:
1. Proof of all income from the previous year or 12 months from the date you turn in your application.

Most recent income Tax Form 1040A or 1040 and W-2 formsPay stubs or written statement for all jobsDocumentation of TANF, SSI or HomelessnessDocumentation of Child Support
Should be Empty:

Head Start Application

SECTION 1: APPLICANT INFORMATION

SECTION 2: DISABILITIES INFORMATION

SECTION 3: FAMILY INFORMATION

SECTION 4: EDUCATION/EMPLOYMENT INFORMATION

Language:

Employment:

Employer:

Education

Language:

Employment:

Employer:

Education

SECTION 5: CHILD CARE INFORMATION

SECTION 6: HOUSING INFORMATION

SECTION 7: TRANSPORTATION INFORMATION

SECTION 8: PROGRAM INFORMATION

FOR EHS ONLY:

SECTION 9: FAMILY ASSISTANCE INFORMATION

SECTION 10: EXPECTANT WOMAN INFORMATION FOR PREGNANT WOMEN ONLY

SECTION 11: SIGNATURES

For OfficeUse Only