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Head Start/ECEAP/Early Head Start Initial Application
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2022-07-12T14:02:04-07:00
Head Start/ECEAP/Early Head Start Initial Application - V7
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. Vacancies occur in all classrooms throughout the year. When this happens, we will continue to accept children.
If your child is selected for enrollment, you will receive a letter in the mail no later than August 31, 2022. This letter will inform of what your next steps are to complete the enrollment process.
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
*
Month
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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(s):
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
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30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender Identity
*
Female
Male
Is this child a member of a tribal nation?
*
Yes
No
This child speaks
*
Only English
Mostly English, and some of another home language
Some English, but mostly another home language
English and another language at age level (bilingual)
Only a home language other than English
Child's Secondary language
Enter other language
What race do you consider your child?
*
White
Black/African American
American Indian
Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Multi-Racial/Biracial
Other
If American Indian, name of tribe
If Alaska Native, specify
If Asian, describe
If Native Hawaiian/Other Pacific Islander, specify
If Multi-Racial/Biracial, specify
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, or after living in an orphanage in another country? (this does not include other adoptions)
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
Child Protective Services (CPS)
Is this child's family actively involved in and/or receiving support from Tribal or State Systems including Child Protective Services (CPS), Family Assessment Response (FAR), Indian Child Welfare (ICW), comparable Tribal services or Law Enforcement/court system regarding child abuse, neglect, or sexual assault?
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
Previous Enrollment
This child was previously enrolled in:
Head Start at Opportunity Council
ECLIPSE
Head Start with a different agency
ESIT - Early Support for Infants and Toddlers
Migrant/Seasonal Head Start anywhere in Washington
Early Head Start
Any birth to three home visiting program
Early ECEAP
Part C IDEA Early Intervention program in another state
Name of ESIT Provider
Name of EHS grantee
Name of ECEAP contractor
Provider name and state
About Your Family
Language(s) Spoken:
*
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
2
3
4
5
6
7
8
9
10
11
12
Day
1
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31
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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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1936
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1933
1932
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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
Housing (Select one)
*
Rent or own an adequate residence
Doubled-up with another family for convenience, choosing to be close to family or friends, choosing to save money for future plans.
Doubled-up with another family due to loss of housing, economic hardship, or a similar reason
In an emergency or transitional shelter
Sleeping in a hotel, motel, car, park, campsite or similar location
Moving from place to place (couch surfing)
Inadequate housing such as no water, heat or electricity; excessive mold; or no cooking facilities
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
3
4
5
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23
24
25
26
27
28
29
30
31
Year
2024
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/Kindship
Child lives with this parent?
*
Yes
No
Interpreter Needed
Do you need an interpreter to communicate with English speaking staff?
Yes
No
If an interpreter is needed, what language do you speak?
*
Living Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
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
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
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
What race do you consider yourself
*
White
Black/African American
American Indian
Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Multi-Racial/Biracial
Other
American Indian - Name of Tribe
*
Alaska Native - Describe
*
Asian - Describe
*
Native Hawaiian/Other Pacific Islander - Describe
*
Multi-Racial/Biracial - Describe
*
Other - Describe
*
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
2024
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
Child lives with this parent?
*
Yes
No
Interpreter Needed
Do you need an interpreter to communicate with English speaking staff?
Yes
No
If an interpreter is needed, what language do you speak?
*
Living Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
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
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
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
What race do you consider yourself?
*
White
Black/African American
American Indian
Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Multi-Racial/Biracial
Other
American Indian - Name of Tribe
Alaska Native - Describe
Asian - Describe
Native Hawaiian/Other Pacific Islander - Describe
Multi-Racial/Biracial - Describe
Other - Describe
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
This child has a diagnosed developmental delay or disability with no IEP.
Yes
No
This child completed a developmental screening that recommended referral for further evaluation.
Yes
No
This child has a suspected developmental delay or disability.
(No IEP, diagnosis, or screening, or completed developmental screening with result, "rescreen needed."
Yes
No
If yes, describe
Does your child currently have an Individual Family Service Plan (IFSP)?
*
Yes
No
If yes, who is your Family Resource Coordinator (FRC)?
Does this child have diagnosed disability, behavior or a medical condition that may require extra services?
Yes
No
Please explain:
Does your household receive subsidized housing, such as a housing voucher or cash assistance for housing?
Yes
No
Does this child have a family member who attended an Indian boarding school?
Yes
No
Did a Child Welfare Agency (CPS)refer your family to Head Start/ECEAP?
*
Yes
No
Has this family previously received support or been involved in tribal or state systems?
Including CPS/FAR/ICW services, or comparable tribal service, or been involved with law enforcement/court system regarding child abuse, neglect or sexual assault?
Yes
No
Are you receiving services through any other agencies? Please list.
(Health Department, Brigid Collins, etc.)
Has this child experienced homelessness within the last 12 months?
Yes
No
Do you receive subsidized housing (low-income housing or Section 8)?
*
Low-Income Housing or Section 8
Yes
No
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.
Phone
This field is for validation purposes and should be left unchanged.
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