Portal

$BVCAnewlogo.jpg$

Blue Valley Community Action

Head Start 0-5 Application

Select Location:

Location:*

Family Information:

Number of household members: include everyone living in the home

Number of individuals in the family: related by blood, marriage or adoption

What is your current housing situation:

Were you referred by Welfare?

Are you a Military Family (active or veteran)?

Do you receive SNAP (food stamps)?

Do you receive SSI?

Are you currently or have you formerly received TANF or ADC

Do you receive WIC?

Do you Receive Any Other Public Assistance?

Primary Adult:

Primary Adult - First and Last Name*

Primary Adult - Date of Birth*

Primary Adult - Primary Phone Number

Click here to opt in to receive program updates by text message

Primary Adult - eMail Address

Click here to opt in to receive program updates by email

Primary Adult - Gender:

Primary Adult - Education:

Primary Adult - Living Address:

Primary Adult - City:

Primary Adult - State

Primary Adult - Zipcode:

Does the Primary Adult havea a Different Mailing Address?

Primary Adult - Mailing Address:

Primary Adult - Mailing City:

Primary Adult - Mailing State

Primary Adult - Mailing Zipcode:

Income Information:

Primary Adult - Employment Status:

A Income Source	B Amount Annually

Add New Entry

Is the Primary Adult Receiving Child Support

Primary Adult - Amount of Child Support you are receiving

Race: (select all that apply)

Asian

Black

Native American

Pacific Islander

White

Other

Primary Adult - Other Race:

Primary Adult - Ethnicity

Primary Adult - Primary Language Spoken at Home:

Primary Adult - What is Proficiency of Primary Language Spoken?

Does primary adult speak any other language?

Primary Adult - List Other Language Spoken:

Primary Adult - Other Language Proficiency:

Page Break

Secondary Adult:

Secondary Adult - First and Last Name:

Secondary Adult - Date of Birth

Secondary Adult - Phone Number:

Click here to opt in to receive program updates by text

Secondary Adult - Email Address

Click here to receive program updates by email

Secondary Adult - Gender:

Secondary Adult - Education:

Secondary Adult - Race: (select all that apply)

Asian

Black

Native American

Pacific Islander

White

Other

Secondary Adult - Other:

Secondary Adult - Ethnicity:

Secondary Adult - What is Primary Language Spoken?

Secondary Adult - What is proficiency of Primary Language Spoken?

Does secondary adult speak any other language?

Secondary Adult - list other language spoken

Secondary Adult - Other Language Proficiency:

Income Information:

Secondary Adult - Employment Status:

A Income Source	B Amount Annually

Add New Entry

Is the Secondary Adult Receiving Child Support?

Secondary Adult - Amount of child support you are receiving

Page Break

Applicant Information (Child #1):

Select the program year you wish to apply for:

Select the program you wish to apply for:

Child #1 - First Name:

Child #1 - Middle Name:

Child #1 - Last Name:

Child #1 - Date or Birth:

Child #1 - Gender:

Child #1 - Race:

Asian

Black

Native American

Pacific Islander

White

Other

Child #1 - Please specify other Race:

Child #1 - Ethnicity

Child #1 - Is this child Hispanic/Latino?

Child #1 - What is Primary Language Spoken?

Child #1 -What is Proficiency of Primary Language Spoken?

Does Child #1 Speak another language?

Child #1 - Other Language Spoken?

Child #1 - Other Language Proficiency:

Child #1 - Parent Status

What is the primary adults relationship to Child #1

Does the Primary Adult Mentioned above have Custody of Child #1?

What is the secondary adults relationship to Child #1

Does the Secondary Adult Mentioned above have Custody of Child #1?

Does Child #1 receive Medicaid benefits?

Child #1 - Medicaid Number:

Does Child #1 have private insurance?

Name of Insurance Company

Child #1 - Insurance Number:

Child #1 - Is this child receiving special education services?

Please list any other family members:

A Adult/Child	B Last Name	C First Name	D Birthday	E Gender

Add New Entry

Page, Print Break

Do you have another child you wish to apply for a program? If not, skip to the next section:

Applicant Information (Child #2):

Select the program year you wish to apply for:

Select the program you wish to apply for:

Child #2 - First Name:

Child #2 - Middle Name:

Child #2 - Last Name:

Child #2 - Date or Birth:

Child #2 - Gender:

Child #2 - Race:

Asian

Black

Native American

Pacific Islander

White

Other

Child #2 - Please specify other Race:

Child #2 - Ethnicity

Child #2 - Is this child Hispanic/Latino?

Child #2 - What is the Primary Language Spoken?

Child #2 - What is Proficiency of Primary Language Spoken?

Does Child #2 Speak another language?

Child #2 - Other Language Spoken?:

Child #2 - Other Language Proficiency:

Child #2 - Parent Status

What is primary adults relationship to Child #2

Does the Primary Adult Mentioned above have Custody of Child #2

What is secondary adults relationship to Child #2

Does the Secondary Adult Mentioned above have Custody of Child #2?

Does child #2 receive Medicaid benefits?

Child #2 - Medicaid Number:

Does child #2 have private insurance?

Name of Insurance Company

Child #2 - Insurance Number:

Child #2 - Is this child receiving special education services?

Page Break

Is the primary or secondary adult pregnant and interested in EHS or CCP services? If yes, please complete this section. If no, skip to the next section

Pre-Natal Information For Current Pregnancy:

Select the program you wish to apply for: (may select more than one)

Early Head Start

CCP (Jefferson and Saline only)

Mothers Legal Name

First and Last Name

Date of Birth

Expected Delivery Date?

When did you first receive prenatal care?

Is this pregnancy considered high risk?

Page Break

Emergency Contact Information:

Mother Work Phone

Mother Employed By:

Mother Regular Hours Per Week

Father Work Phone

Father Employed By:

Father Regular Hours Per Week

Doctor Information:

Doctors Name:

Address:

City:

State

Zipcode:

Phone Number

Dentist Information:

Dentist Name

Address:

City:

State

Zipcode:

Phone Number

Child #1 - List Allergies or Medical Conditions (If Applicable):

Child #2 - List Allergies or Medical Conditions (If Applicable):

I give Head Start 0-5 permission to post my child's allergy and picture in the classroom?

Do Not Release To - only applies if there is a court document

Name:

Relationship:

Name:

Relationship:

If someone other than who is on the list above is to pick-up your child or is to get them off the bus a signed note by the parent/guardian is required. If they are not on the list or there is no note the child will not be released to that person. Picture identification is required for adults that staff are unfamiliar with.

Additional Emergency Contacts:

A Name	B Phone	C Relationship	D Contact in Emergency?(y/n)	E Release to? (y/n)

Add New Entry

Page Break

We are requesting the following documents:

If you do not have the documents available, please continue and submit your application. Staff will follow up with you to make arrangements to get the documents needed:

Upload Documents for Verificaton:

Please Attach Birth Certificate

Take Picture/Video

Please Attach Proof of Income

Take Picture/Video

Please Attach Immunization Record

Take Picture/Video

Please attach the following documents if applicable:

Please Attach IFSP/IEP Verification

Take Picture/Video

Please Attach Court Documents(if applicable)

Take Picture/Video

Certification: I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours

IMMEDIATE EMERGENCY: In case of an immediate emergency, I give my permission to use the nearest Doctor, Dentist, and/or facility available.

Parent/Guardian Signature:

Signature - Please type your name in the box below. By typing your name you confirm that all information that is being submitted on this form is true and accurate.*

Date*

If you have additional children you wish to apply for, please begin a new application and submit it seperately.