Form Test

About You

Parent/Guardian #1*

First Last

Date of Birth*

Relationship to Child

Living Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #1 Mailing Address same as living address?*

Yes
No

Mailing Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Can we send you text messages/updates?

Yes
No

Email

Child lives with this parent?*

Yes
No

What race do you consider yourself?

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Multi Racial/Biracial
Unspecified
Other

Hispanic/Latino?*

Yes
No

Highest level of education for this parent/guardian?*

Parent/Guardian #2

First Last

Date of Birth

Relationship to Child

Living Address

Street Address Address Line 2 City State ZIP Code

Parent/Guardian #2 mailing address same as living address?

Yes
No

Mailing Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Can we send you text messages/updates?

Yes
No

Email

Child lives with this parent?

Yes
No

What race do you consider yourself?

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Multi Racial/Biracial
Unspecified
Other

Hispanic/Latino?

Yes
No

Highest level of education for this parent/guardian?

Head Start/ECEAP/Early Head Start Initial Application - V6

Step 1 of 8 - About Your Child

Initial Application

About Your Child

About Your Family

About You

Household Info

Health and Social Services Information

Concerns and Challenges

Certification

Optional - Verification of Age and Income File Upload

Catholic Community Services
Child Protective Services
Church
Door Hanger/Tear-Off/Flyer
Doctor or Dentist
DSHS (office)
East Whatcom Regional Resource Center
Family/Friend
Facebook
Housing Case Manager
Library
Opportunity Council Staff
Opportunity Council Website
Outreach Event
Current/Past Enrolled Parent
School District Staff
School or College
Sibling Attended/Enrolled
Walk-in
WCEL/Special Needs Referral
WIC Program
Other organization:

Child abuse/neglect issue(s) (CPS)
Child development concerns
Child weighed less than 5.5lbs when born
Disability - Parent/Guardian
Deployed Military Parent/Guardian
Domestic violence (past or present)
English Language Learner
Health referral/Medical/Mental health concerns (child)
Health referral/Medical/Mental health concerns (parents)
Homeless*
Involved in criminal justice system
Foster Child
Guardian has less than 10th grade education
Maternal/Paternal depression or mental health concerns
Migrant worker
No support system
No transportation
Parent/guardian in the military
Parent/guardian unemployed
Past involvement with HS/ECEAP/EHS
Past or present drug/alcohol rehabilitation of a parent
Past or present incarcerated Parent/Guardian
Premature birth
Social Services referral
Substance abuse
Teen Parent