Head Application Form Name: MI: Last Name: DOB:* Gender:  Male  Female Race*(Check only one) American Indian/Alaskan Native  Hispanic/Latino Asian  Native Hawaiian or Other Pacific Islander Black or African American  White Bi-racial/Multi-Racial Specify Other Specify Unknown Ethnicity: (Please specify below) Person’s Ethnicity is Latino or How well does the child speak English? Very well  Well Not well  Not at all Language spoken at home: Primary  English  Spanish  Other _ _ Secondary  English  Spanish  Other _ _ LIVING ADDRESS Street Address: Apt. # City: State: Zip Code: School District: MAILING ADDRESS □ Same as living address Street Address: Apt. #: City: State: Zip Code: PARENT/GUARDIAN Name: MI: Last Name: DOB:* Gender:  Male  Female Phone: Can you receive texts?  Yes  No Email address: Marital Status: Married  Single  Separated  Divorce  Partner Person is Head of Household: Yes  No Relationship to Child: Biological parent  Grandparent  Parent’s significant other  Foster Parent  Legal guardian Step Parent  Person lives in same household as child?  Yes  No Is person currently pregnant?  Yes  No If yes, when is due date:
Highest of Education Completed: Date Completed: ___ ___ ___ Race*: only one) American Indian/Alaskan Native  Hispanic/Latino Asian  Native Hawaiian or Other Pacific Islander Black or African American  White Bi-racial/Multi-Racial Specify Other Specify Unknown Ethnicity: (Please specify below) Person’s Ethnicity is Latino or Hispanic How well does this person English? Very well  Well Not well  Not at all Occupational Status:  Full Time  Part Time  Retired  Unemployed  Home Maker  Disabled Employer: Address: _ _ _ _ Telephone: Work Hours: _ _ _ Education Status:  School Full Time  School Part Time  School Hours: _ _ School: Address: _ _ Telephone: _ _ _ _ _ #2 PARENT/GUARDIAN First Name: MI Last Name: DOB:* Gender: □ Male □ Female Can you receive texts?  Yes  No Email address: Marital Status: Married  Single  Separated  Divorce  Partner Person is Head of Household: Yes  No Relationship to Child: Biological parent  Grandparent  Parent’s significant other  Foster Parent  Legal guardian Step Parent  Other Person in same household as child?  Yes  No Is person currently pregnant?  Yes  No If yes, when is due date? Race*: (Check only one) American Indian/Alaskan Native  Hispanic/Latino  Native Hawaiian or Other Pacific Islander or African American  White Bi-racial/Multi-Racial Specify Other Specify Unknown Ethnicity: (Please specify below) Person’s Ethnicity is Latino or Hispanic How well does this person speak English? Very well  Well Not well  Not at all Highest Level of Education Completed: Date Completed:___ ___ ___ __ ___
Family is homeless: Yes  No (If yes you must explain living situation and fill out homeless information) Type of Housing: House  Apartment  Mobile Home  Community Shelter  Homeless  Hotel/Motel  Other Family Housing Payment Type: Exchange Services for Housing  Make No Payment for Housing  Own  Rent Receive Subsidized Housing Other Do you have of transportation?  Yes  No Primary Mode of transportation:  Personal Car  Friends Car  Bus  Taxi  Public Transportation Other How did your family hear about Head Start (Referral from where?)*
REFERRALS MADE TO LOCAL AGENCIES Medical  Mental Health  Special Education  Transportation Healthy Relationships  Basic Needs  Education  Child Care ECKAN Services  Other(specify) SIBLINGS Name: DOB: Race: Gender: Name: DOB: Race: Gender: Name: DOB: Race: Gender: Name: DOB: Race: Gender: Name: DOB: Race: Gender: Name: DOB: Race: Gender: Name: DOB: Race: Gender: Parent Signature: Date: Signature: Date: Parent Signature: Date: Staff Signature: Date: Parent Signature: Date: Staff Signature; Date:
ECKAN HEAD START EMERGENCY CONTACT/RELEASE FORM Child’s Name: DOB: Mother/Mother Figure’s Name: Phone 1: 2: Father/Father Figure’s Name Phone 1: Phone 2: Emergency Contacts Name: Relationship to Child: Phone 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Phone 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: Phone 1: Phone 2: Date: Pick up & Emergency Contact Emergency Contact Only Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only Name: Relationship to Child: Phone 1: Phone 2: Date: Pick Up & Emergency Contact  Emergency Contact Only  Pick Up Only I authorize ECKAN Head Start staff to contact the names listed above in case of an emergency. I also give permission to release my child to the name listed above. Parent Signature Date: Update(s): Parent Initials Date: Parent Initials Date: Parent Initials Date: Parent Initials Date: Parent Initials Date: Parent Initials Date:_