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Head Start/ECEAP/Early Head Start Initial Application
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2019-03-18T16:00:10-07:00
Head Start/ECEAP/Early Head Start Initial Application - V5
Thank you for your interest in our program for young children. Please complete the following form to begin the application process.
Step 1 of 9 - About Your Child
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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
*
Month
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12
Day
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1930
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Parent/Guardan 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
I am receiving weatherization, home repair or Healthy Homes 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
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
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
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
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic/Latino?
*
Yes
No
If your child is of Hispanic or Latino ethnicity, what is the family's country of origin?
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 this child's family currently receiving Child Protective Services (CPS)?
*
Yes
No
Is the family currently receiving Family Assistance Response (FAR) services?
*
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.
Does this household receive subsidized housing, such as a housing voucher or cash assistance for housing?
*
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
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
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11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
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
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
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
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
Race
*
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic/Latino?
*
Yes
No
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
Email
Child lives with this parent?
*
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
Relationship to Child
Parent
Foster Parent
Guardian/Kinship
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
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
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic/Latino?
Yes
No
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
Email
Child lives with this parent?
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
About Your Income
This is required information
Parent/Guardian 1
Main source(s) of income
*
Work
TANF/SSI
Unemployment
Other
If working, please enter the number of paid work hours per week:
Please enter employer name and phone or email
Are you enrolled and attending school or job training?
*
Yes
No
Name of school or training organization
*
Goal or major:
*
Number of class hours per week when school is in session:
How many hours do you spend doing homework and traveling to/from classes?
Is this parent/guardian in an approved WorkFirst activity other than employment, education or job training mentioned above?
*
Yes
No
If yes, describe activity
Number of approved hours per week
Are you currently receiving services through TANF, or have you in the past year?
*
Yes
No
Parent/Guardian 2
Main source(s) of income
Work
TANF/SSI
Unemployment
Other
If working, please enter the number of paid work hours per week:
Please enter employer name and phone or email
Are you enrolled and attending school or job training?
Yes
No
Name of school or training organization
Goal or major:
Number of class hours per week when school is in session:
How many hours do you spend doing homework and traveling to/from classes?
Is this parent/guardian in an approved WorkFirst activity other than employment, education or job training mentioned above?
Yes
No
If yes, describe activity
Number of approved hours per week
Are you currently receiving services through TANF, or have you in the past year?
Yes
No
Please List Other People Living With You
*
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?
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
Concerns and Challenges
Please share your concerns and challenges
*
Select all that apply to you or your family.
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
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.
Upload Verification of Child’s Age
Birth Certificate or Hospital Certificate
X
