Head Start On-Line Application

Application

Application for the
Enfield Public Schools Head Start Program
at the Stowe Early Learning Center

117 Post Office Road, Enfield, CT 

 

 


Date: (MO/DY/YEAR) 


Child’s Legal Name (must match birth certificate):

           

    (First name)          (Middle name)         (Last name)

Nickname: 


Date of Birth: (MO/DY/YEAR)  


Who is submitting this application: Mother Father Both  Guardian

Who does child live with?:  Mother  Father   Both Guardian

Marital Status:  Married  Single Divorced Widowed

Address:  

Phone  (xxx-xxx-xxxx) :   

Email:    

How long have you lived in Enfield? 

Where did you reside prior? 

Country of Origin: 

Race: 

Gender: Male   Female


Language(s) spoken at home? 


If foster child, name of the state worker: 

Is there a surrogate parent assigned?  Yes   No      If yes, name: 



Number of person(s) in home: 

Household Information

Adult's NameRelationship to childDate of birthSexOccupation

Children in Home

Child's nameDate of BirthSex


Has your child been diagnosed with a disability or received services from Birth to Three?  Yes   No

If Yes, what was the diagnosis:   

Services received: 


Does any person listed above have any health problems?  Yes   No

If yes, describe: 


Referred to program?  Yes   No  By Whom? 


Has your child had any pre-school or childcare experience?  Yes    No

If yes, where:   


Have you had any children the Head Start program in the past?  Yes    No


Are you receiving any state benefits?  Yes   No

If Yes, What benefits are you receiving? 



Are there any specific family needs or crisis?  Yes   No

If yes, please describe: 


Income: List by family member:

Income List
Family MemberAmount receivedweekly, monthly, yearlySource
Week Month Year
Week Month Year
Week Month Year

 

Yearly GROSS income by family $   

Verified by (staff member) 

Type of verification: 



  Certification: I certify that this information is true. If any part is false, my participation in this agency’s program may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency.  

 

Signature of parent or guardian _______________________________ Date ___________________

Signature of staff member        ________________________________ Date ___________________

 

You may also drop this form off to the front desk at Stowe Early Learning Center.


Be sure to click on the submit button below(only once).



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