UAMS Head Start/Early Head Start

2012-2013 Program Year

Select Program Year for which you are applying:

Program Year:

2012-2013

Primary Site Preference:

Child Information

Please fill out the information below for the child applying to UAMS Head Start/Early Head Start Program.

Child's Name:

Child's Date of Birth:

Child's Gender:

Male
Female

Will your child be 3 years old by August 1, 2012?

Child's Primary Language at home:

Please Select Child's Race/Ethnicity:

Native American or Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
Hispanic/Mexican
White/Caucasian
Multi/Bi-racial
Other

Hispanic?

Yes
No

Child's Primary Health Insurance:

Medicaid
ArKids First
Private
Military
No Health Insurance

Child's Doctor Name:

Child's Dentist Name:

Family Information

Fill out this section with the current Family Information of the applying child.

Living Address:

Address Line 2:

City:

Zip Code:

Primary Phone Number:

Alternate Phone Number:

Are you Currently Homeless?:

Yes
No

Emergency Contact Name:

Emergency Contact Phone Number:

Emergency Contact Relationship to Child:

How many people currently live in your home? (Please count everyone living in your home including yourself and select the number below.)

Number in Household:

What was your family's total YEARLY income for 2011? Please add income from all sources (salary, child support, unemployment, etc.) that your family received and enter the number below in US Dollars).

Yearly Income:

Number of Adults in your household:

Number of Children in your household:

Please select any of the following statements if it applies to you or a member of your family. Please select all that apply:

Please check all services your family currently receives:

Child Welfare Services
Food Stamps/SNAP
SSI
TANF
WIC

Primary Adult Information

Fill out this section for the Primary Adult/Guardian/Caretaker of the applying child.

Primary Adult Gender:

Primary Adult Name:

Primary Adult Date of Birth:

Primary Adult Email:

Select Primary Adult Race/Ethnicity:

American Indian or Alaskan native
Asian
Black or African American
Native Hawaiian or Pacific Islander
Hispanic/Mexican
White/Caucasian
Multi/Bi-racial
Other

Hispanic:

Yes
No

Please select highest grade completed in school:

Select Employment Status:

Does the child live with you?

Primary Adult's Relationship to Child?

Parental Status

Secondary Adult Information

Please ONLY fill out this section for the Secondary Adult to the applying child. If you are a single parent you can skip this section.

Secondary Adult's Gender:

Secondary Adult Name:

Date of Birth:

Select Secondary Adult's Race/Ethnicity:

American Indian or Alaskan native
Asian
Black or African American
Native Hawaiian or Pacific Islander
Hispanic/Mexican
White/Caucasian
Multi/Bi-racial
Other

Hispanic:

Yes
No

Please select highest grade completed in school:

Select Employment Status:

Other Children

Fill Out this section with siblings information of the applying child, EXCLUDING the applying child listed above. If there are no siblings please skip this section.

1. Child Name:

Date of Birth:

Gender:

Male
Female

2. Child Name:

Date of Birth:

Gender:

Male
Female

3. Child Name:

Date of Birth:

Gender:

Male
Female

4. Child Name:

Date of Birth:

Gender:

Male
Female

Referral Information

How did you hear about us? Please Select:

Agency Referral
Early Head Start
Family or Friend
Flyers
Other:

Where did you complete this application?

Verification (electronic signature required):

Verification: I certify that the information provided in this application, and the income indicated for enrollment eligibility, is accurate and truthful to the best of my knowledge. Providing false income/information could result in dismissal from the program and may be subjected to legal action. I also understand that the information given to the program will remain confidential and is accessible to me during normal business hours.

Electronic Signature:

UAMS Pediatrics - Head Start Program

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UAMS Head Start/Early Head Start

2012-2013 Program Year

Child Information

Family Information

Primary Adult Information

Secondary Adult Information

Other Children

Referral Information

How did you hear about us? Please Select:

Where did you complete this application?

Verification (electronic signature required):

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