Head Start/ECEAP/Early Head Start Initial Application

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*
Parent/Guardan Name:*
First Middle Last
How did you hear about us?*
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:
Name of Case Manager

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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?

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Please List Other People Living With You*
Name Relationship Date of Birth

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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?
Does your child currently have an Individual Family Service Plan (IFSP)?*
- Yes
- No
If yes, who is your Family Resource Coordinator?
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

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Concerns and Challenges
Please share your concerns and challenges*
Select all that apply to you or your family.
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.

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Insurance
Does your child have medical insurance coverage?*
- Yes
- No
Does your child have dental insurance coverage?*
- Yes
- No
Check all that apply:
- Medicaid/DSHS/Apple Health (Molina, Community Health, etc.)
- Private Insurance
- Other:
If other, please list:
Name of your child's Health Care Plan or Company:

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Child's Birth Information
Is this child adopted?*
- Yes
- No
If yes, at what age?
Birth weight*
lbs oz
Were they any difficulties with this pregnancy?*
(bleeding, high blood pressure, persistent vomiting, illnesses)
- Yes
- No
Was your child born early?*
- Yes
- No
If yes, how early?
Where there any concerns for your child at birth?*
- Yes
- No
If yes, please explain:
Did you (or birth mother) use alcohol or drugs during pregnancy?*
- Yes
- No

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Medical History
Is your child currently diagnosed with any of the following?*
If other, please list:
Has your child experienced any of the following within the past six months?*
If other, please list
Has your child received a blood drawn lead test?*
- Yes
- No
Has your child ever been hospitalized?*
- Yes
- No
Has your child ever had a serious accident?*
- Yes
- No
Has your child ever had a head injury?*
- Yes
- No
If yes, please explain:

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Life Threatening Conditions
Does your child have a life threatening condition? (i.e. seizure disorder)*
If yes, Washington State Law RCW 28A.210.320 requires that mediation or treatment orders and a health care plan is in place PRIOR to the child starting school.
- Yes
- No
Describe Condition*

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Cow Milk
Is your child lactose intolerant?*
- Yes
- No
Allergies
Does your child have any allergies?*
- Yes
- No
Select all that apply:*
Food - Please Specify Allergy*
Other - Please Specify Allergy*
Please describe the allergic reaction and the treatment*
Will medication/treatment be needed at school?*
- Yes
- No
Medications
Does your child take any medication?*
- Yes
- No
If yes, please list the name and purpose medication(s):*
Name Purpose
Will medication be needed at school?*
- Yes
- No
If yes, please list the name and purpose medication(s):*
Name Purpose

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Extras
Do you have any concerns about your child's development?*
- Yes
- No
If yes, please describe:
Has your child received Mental Health counseling or Family Therapy?*
- Yes
- No
If currently seeing a counselor, name of person and/or agency:
Does your child currently have an Individual Education Plan (IEP) or has been tested by a school district?*
- Yes
- No
If yes, which school district?
Has your child been involved with any of the following specialists or agencies in the past two years? If so, please give the name of the specialist, therapist or case manager and explain the reason for services:
Children's Neurodevelopmental Program (CNP)
Please provide name of the specialist, therapist or case manager and explain the reason for services
Health Department/Developmental Clinic
Please provide name of the specialist, therapist or case manager and explain the reason for services
OT/PT
Please provide name of the specialist, therapist or case manager and explain the reason for services
School District
Please provide name of the specialist, therapist or case manager and explain the reason for services
Social/Case Worker
Please provide name of the specialist, therapist or case manager and explain the reason for services
Speech/Language Therapist
Please provide name of the specialist, therapist or case manager and explain the reason for services
Whatcom Center for Early Learning
Please provide name of the specialist, therapist or case manager and explain the reason for services

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Behavior and Developmental History
Behavior and Developmental History questions apply to children aged 2.5 years or older. If your child is under 2.5 years click next to move on to the Certification page.
My child is 2.5 years or older.*
- Yes
- No
Within the past 6 months has your child:
Within the past 6 months has your child:

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Certification
I certify that the information provided in the Early Learning and Family Services Head Start/ECEAP/Early Head Start Initial Application is accurate and truthful to the best of my knowledge.*
Type name to certify
I understand that program funds can be used to pay for children's health services only after all other resources have been exhausted. Assistance is available to help research funding sources to cover health care costs for families.*
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.
Upload Verification of Child’s Age
Birth Certificate or Hospital Certificate

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Head Start/ECEAP/Early Head Start Initial Application - V4

Step 1 of 19 - About Your Child

Initial Application

About Your Child

About Your Family

About You

About Your Income

Parent/Guardian 1

Parent/Guardian 2

Health and Social Services Information

Concerns and Challenges

Medical Provider

Dental Provider

Insurance

Child's Birth Information

Medical History

Life Threatening Conditions

Cow Milk

Allergies

Medications

Hearing/Vision

Speech/Language

Extras

Family History

Behavior and Developmental History

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)
Disability - Parent
Deployed Military Parent
Domestic violence
English Language Learner
Health referral/Medical/Mental health concerns (child)
Health referral/Medical/Mental health concerns (parents)
Homeless*
Incarcerated parent
Involved in criminal justice system
Live in foster home
Maternal/Paternal depression or mental health concerns
Migrant worker
No support system
No transportation
Parent has less than 10th grade education
Parent in the military
Parent unemployed
Past involvement with HS/ECEAP/EHS
Premature birth
Social Services referral
Substance abuse
Teen Parent
None of the above

ADD/ADHD
Anemia
Asthma
Bleeding disorder
Chicken Pox
Diabetes
Heart Disease
Hemophilia
Hepatitis A
Hepatitis B
Impetigo
Jaundice
Lead Exposure
Learning Disability
Measles
Meningitis
Mumps
Pica
Polio
Rheumatic Fever
Rotavirus
Scarlet Fever
Seizure disorder
Skin Condition/Eczema
Whooping Cough
None of the Above
Other:

Name	Relationship	Date of Birth

Name	Purpose

Name	Purpose