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Form Test
roark
2021-01-07T07:50:24-08:00
Head Start/ECEAP/Early Head Start Initial Application - V6
Thank you for your interest in our program for young children. Please complete the following form to begin the application process.
Step
1
of
8
- About Your Child
0%
Hidden
Recruitment Event
Field used to track if applicant reached site via a recruitment event
Initial Application
All applications for enrollment in our program go through a detailed selection process that helps us to select children and families with the highest need of our services.
This selection process will begin in early summer and continue until classes are full.
Should your child not be selected, they will be placed on a waiting list. This will not guarantee you a slot this year, but it will leave the possibility open as vacancies occur.
Child's Legal Name
*
First
Middle
Last
Date of Birth
*
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1921
1920
Parent/Guardian Name:
*
First
Middle
Last
How did you hear about us?
*
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:
Name of person/organization who told you about our programs:
Are you currently receiving assistance through any Opportunity Council programs or departments?
*
Yes
No
Please indicate which service:
I am receiving a rental subsidy through Opportunity Council/Opportunity Council is paying my rent
I am living in a housing unit through Opportunity Council
I am staying in a motel through Opportunity Council
I am working with a housing case manager at Opportunity Council
I am receiving veteran services (SSVF) through Opportunity Council
I am receiving energy assistance through Opportunity Council
I am receiving employment services (BFET, Work First, Community Jobs) through Opportunity Council
Name of Case Manager
About Your Child
Child's Legal Name
*
First
Last
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
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14
15
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26
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28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1951
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Sex of child
*
Female
Male
Primary Language
*
English
Spanish
Russian
What race do you consider your child?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Multi Racial/Biracial
Unspecified
Other
If other, please specify:
Hispanic/Latino?
*
Yes
No
If your child is of Hispanic or Latino ethnicity, what is the family's country of origin?
Is this child in official foster care?
*
This means there is a caregiver authorization form fro a state or tribe that says this is a foster care placement.
Yes
No
Was this child adopted after foster or kinship care?
Yes
No
Does your child have medical coverage?
*
Yes
No
If yes, what kind?
e.g. Molina, Community Health Plan
Receiving WIC?
*
Yes
No
Receiving Food Stamps (SNAP) within last 12 months?
*
Yes
No
Is your child in childcare now?
*
Yes
No
If so, where?
Is your child currently enrolled in another Head Start/ECEAP/Early Head Start Program?
*
(i.e. Lummi Nation Head Start, Nooksack Tribal Head Start, etc.)
Yes
No
Has your child had past involvement with Head Start or ECEAP?
*
Yes
No
Was your child ever enrolled in an Early Head Start or home visiting program?
*
Yes
No
Is the family approved for child care through Child Protective Services (CPS) including Family Assessment Response (FAR)?
*
Yes
No
If yes, enter the number of approved hours per week.
Has this child been asked to leave a child care or preschool because of because of behavior issues?
*
ELAFS serves children with behavior issues. Checking yes will not exclude your child
Yes
No
About Your Family
Language(s) Spoken:
*
Parents need interpreter?
*
Yes
No
Number in Family
*
Please enter a number greater than or equal to
1
.
Household Type
*
One-Parent Household
Two-Parent Household
Number of children 0-3 years old:
*
Please enter a number greater than or equal to
0
.
Number of children 4 or 5 years old:
*
Please enter a number greater than or equal to
0
.
Is anyone is your family pregnant?
*
Yes
No
If yes, what is the due date?
Month
1
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Day
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31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
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2002
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2000
1999
1998
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1996
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1992
1991
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1986
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1981
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1979
1978
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1959
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1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Is your family currently receiving service through TANF, or have you in the past year?
*
Yes
No
About You
Parent/Guardian #1
*
First
Last
Date of Birth
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
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12
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23
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25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
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1984
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1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
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1969
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1967
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1965
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1963
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1961
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1953
1952
1951
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1949
1948
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1946
1945
1944
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1941
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Relationship to Child
Parent (biological or adoptive)
Step-parent
Foster Parent
Grandparent/Kindship
Living Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent/Guardian #1 Mailing Address same as living address?
*
Yes
No
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
*
High School (no diploma)
High School Diploma or GED
Trade School or Training Certificate
Associate's Degree
Bachelor's/Advanced Degree
Parent/Guardian #2
First
Last
Date of Birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Relationship to Child
Parent (biological or adoptive)
Step-parent
Foster Parent
Grandparent/Kinship
Living Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent/Guardian #2 mailing address same as living address?
Yes
No
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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?
High School (no diploma)
High School Diploma or GED
Trade School or Training Certificate
Associate's Degree
Bachelor's/Advanced Degree
Household Info
This is required information
Please list everyone living in the household who may be counted in family size:
Name
Relationship
Date of Birth
Health and Social Services Information
Does your child currently have an Individual Education Plan (IEP) or was tested by a school district?
*
Yes
No
If yes, which school district?
Do we have permission to contact the school district for a copy of the IEP?
Yes
No
Does your child currently have an Individual Family Service Plan (IFSP)?
*
Yes
No
If yes, who is your Family Resource Coordinator (FRC)?
Are you receiving services through any other agencies? Please list.
(Health Department, Brigid Collins, etc.)
Do you receive subsidized housing (low-income housing or Section 8)?
*
Low-Income Housing or Section 8
Yes
No
Did a Child Welfare Agency (CPS)refer your family to Head Start/ECEAP?
*
Yes
No
Does this child have diagnosed disability, behavior or a medical condition that may require extra services?
Yes
No
Please explain:
Concerns and Challenges
Please share your concerns and challenges
Select all that apply to you or your family.
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
Premature birth, if yes, how early:
Homeless is defined as sharing the housing of other persons due to loss of housing or economic hardship; are living in motels, hotels, trailer parks, or camping grounds due to lack of alternative adequate accommodations; are living living in emergency or transitional shelters (McKinney-Vento Homeless Assistance Act)
Circumstances that you would like to share:
This may qualify you for additional program supports.
Certification
I certify that the information provided in the Early Learning and Family Services Head Start/ECEAP/Early Head Start Intake Application is accurate and truthful to the best of my knowledge. I authorize and consent to exchanging my household information within the departments in the Opportunity Council agency.
*
Type name to certify
Email
*
Optional - Verification of Age and Income File Upload
If scanned copies are unavailable, Verification of Age and Income can be mailed or submitted in person. Your application will not be complete until all items have been received.
Upload Verification of Income
Either the last 12 months or the last calendar year.
Max. file size: 25 MB.
Upload Verification of Child’s Age
Birth Certificate or Hospital Certificate
Max. file size: 25 MB.
Email
This field is for validation purposes and should be left unchanged.
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