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Blue Valley Community Action
Head Start 0-5 Application
Select Location:
Location:
*
Beatrice
Jefferson
Saline
Seward
Thayer
Wymore
York
Fillmore
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:
Own Your House
Rent House or Apartment
Living with Friends or Family
Homeless Shelter
Hotel/Motel
other
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:
Select One...
Male
Female
Prefer not to say
Primary Adult - Education:
Select One
I am currently enrolled in classes
Some College
Associate Degree
Bachelor's Degree
College Degree/Training Cert.
Master's Degre
General Education Diploma
Grade 9 or less
Grade 10
Grade 11
Grade 12
High School Graduate or Equivalent
Primary Adult - Living Address:
Primary Adult - City:
Primary Adult - State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Primary Adult - Zipcode:
Does the Primary Adult havea a Different Mailing Address?
Primary Adult - Mailing Address:
Primary Adult - Mailing City:
Primary Adult - Mailing State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Primary Adult - Mailing Zipcode:
Income Information:
Primary Adult - Employment Status:
Select One...
Unemployed
Seasonal Work
Employed - Full Time
Employed - Part Time
Self Employed
Retired or disabled
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
American Indian or Alaska Native
Asian
Black or African American
Native Hawiian or Pacific Islander
White
Biracial or Multi-Racial
Other
Primary Adult - Primary Language Spoken at Home:
Primary Adult - What is Proficiency of Primary Language Spoken?
Select Primary Language Proficiency
None
Poor
Moderate
Proficient
Does primary adult speak any other language?
Primary Adult - List Other Language Spoken:
Primary Adult - Other Language Proficiency:
Select Language Proficiency
None
Poor
Moderate
Proficient
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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:
Select One...
Male
Female
Prefer not to say
Secondary Adult - Education:
Associate Degree
Bachelor's Degree
College Degree/Training Cert.
Some College
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
Some High School
High School Graduate or Equivalent
Master's Degree
I am currently enrolled in classes
Secondary Adult - Race: (select all that apply)
Asian
Black
Native American
Pacific Islander
White
Other
Secondary Adult - Other:
Secondary Adult - Ethnicity:
American Indian or Alaska Native
Asian
Black or African American
Native Hawiian or Pacific Islander
White
Bi-Racial or Multi-Racial
Other
Secondary Adult - What is Primary Language Spoken?
Secondary Adult - What is proficiency of Primary Language Spoken?
Select Language Proficiency
None
Poor
Moderate
Proficient
Does secondary adult speak any other language?
Secondary Adult - list other language spoken
Secondary Adult - Other Language Proficiency:
Select Language Proficiency
None
Poor
Moderate
Proficient
Income Information:
Secondary Adult - Employment Status:
Select One...
Unemployed
Seasonal Work
Employed - Full Time
Employed - Part Time
Self Employed
Retired or Disabled
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
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Applicant Information (Child #1):
Select the program year you wish to apply for:
2021-2022 (current year)
2022-2023 (next year)
2021-2022 and 2022-2023
Select the program you wish to apply for:
Head Start (3-5 year olds)
Early Head Start (0-3 year olds)
CCP (Jefferson/Saline Only) (0-3 year old)
EHS & CCP
Child #1 - First Name:
Child #1 - Middle Name:
Child #1 - Last Name:
Child #1 - Date or Birth:
Child #1 - Gender:
Select One...
Male
Female
Prefer not to say
Child #1 - Race:
Asian
Black
Native American
Pacific Islander
White
Other
Child #1 - Please specify other Race:
Child #1 - Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Native Hawiian or Pacific Islander
White
Bi-Racial or Multi-Racial
Other
Child #1 - Is this child Hispanic/Latino?
Select One...
Yes
No
Child #1 - What is Primary Language Spoken?
Child #1 -What is Proficiency of Primary Language Spoken?
Select Primary Language Proficiency
None
Poor
Moderate
Proficient
Does Child #1 Speak another language?
Child #1 - Other Language Spoken?
Child #1 - Other Language Proficiency:
Select Language Proficiency
None
Poor
Moderate
Proficient
Child #1 - Parent Status
One Parent
Two Parents
What is the primary adults relationship to Child #1
Select One
Parent/Guardian
GrandParent/Other Family
Foster Parent
other
Does the Primary Adult Mentioned above have Custody of Child #1?
What is the secondary adults relationship to Child #1
Select One
Parent/Guardian
Grandparent/other relative
Foster Parent
other
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?
Select One...
Yes
No
In the process of being evaluated for 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:
2022-2023 (current year)
2023-2024 (next year)
2022-2023 and 2023-2024
Select the program you wish to apply for:
Head Start (3-5 year olds)
Early Head Start (0-3 year olds)
CCP (Jefferson/Saline only) (0-3 year olds)
Multiple Programs Desired
Child #2 - First Name:
Child #2 - Middle Name:
Child #2 - Last Name:
Child #2 - Date or Birth:
Child #2 - Gender:
Select One...
Male
Female
Prefer not to say
Child #2 - Race:
Asian
Black
Native American
Pacific Islander
White
Other
Child #2 - Please specify other Race:
Child #2 - Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Native Hawiian or Pacific Islander
White
Bi-Racial or Multi-Racial
Other
Child #2 - Is this child Hispanic/Latino?
Select One...
Yes
No
Child #2 - What is the Primary Language Spoken?
Child #2 - What is Proficiency of Primary Language Spoken?
Select Language Proficiency
None
Poor
Moderate
Proficient
Does Child #2 Speak another language?
Child #2 - Other Language Spoken?:
Child #2 - Other Language Proficiency:
Select Language Proficiency
None
Poor
Moderate
Proficient
Child #2 - Parent Status
One Parent
Two Parents
What is primary adults relationship to Child #2
Select One
Parent/Guardian
Grandparent/other relative
Foster Parent
other
Does the Primary Adult Mentioned above have Custody of Child #2
What is secondary adults relationship to Child #2
Select One
Parent/Guardian
Grandparent/other relative
Foster Parent
other
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?
Select One...
Yes
No
In the process of being evaluated for 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?
Select One...
Yes
No
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Zipcode:
Phone Number
Dentist Information:
Dentist Name
Address:
City:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
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?
Yes
No
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
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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.
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