Headstart Online Application Parent/Guardian Information Last Name First Name M.I Date of Birth Address City Zip County Phone Number Alternate Number Email Marital Status SingleMarriedDivorcedSeparatedWidowed Are you currently in any type of school or training? YesNo Do you have a high school diploma or GED? YesNo If you are a guardian, do you receive cash assistance for the child(ren) in your care? YesNo Do you have a referral from another agency? If so, please attach documentation. YesNo Are any of your children diagnosed with a special need or disability? YesNo If yes, which children: Do you have concerns for your children’s health or development? YesNo If yes, please explain: Children Information Name DOB Sex Relationship to child Medicad In School? Where? MF YN MF YN MF YN MF YN MF YN Adults in Household Name DOB Employer Income Information Type of Income Parent/Guardian Spouse Child/Other Child Support (All children in household) Welfare Transition(Cash Assistance) Other Income(SSI, Social Security, Etc Center Locations: Vetter, Chapman, Massalina, Millville /Margret Lewis, Early Education (East Ave.), Bayou George, Arnold, Home-Based, Rosenwald, Catherine’s House, Community Child Care Partner, Apalachicola, Franklin Co. Agreement & Terms I verify that the information provided is true and correct. If there are any changes concerning my status, it is my responsibility to contact Early Education and Care, Inc. I understand the information given on this application can be shared for eligibility determination and service referrals to programs operated through the local school district, Head Start, early care and education providers and the Department of Children and Families. I understand that this application is not complete until I have submitted income verification for my child, and that completing this form does not guarantee placement in the above program. I have read and fully understand the above Agreement and Certification and agree to its terms.