HeadStartOnlineApplication | Prairie Five Community Action

Prairie Five Head Start Application

Step 1 of 3

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Please select the program and town that you would like your child to attend.

Program

Town

Days Attending

Monday

Tuesday

Wednesday

Thursday

Preference for AM/PM (not guaranteed)

Name

First Middle Last

Birthday

Gender

Male

Female

Social Security #(Required)

Hispanic/Latino

Yes

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Primary Language

English

Spanish

Chuukese

Other

Foster Child

Yes

Child's Custody Status *(Must include legal documentation from the social worker, court papers, or other documentation as appropriate)

Both Parents

Mother Only

Father Only

Parent Appointed Guardianship*

Foster Care*

Court Ordered Guardianship/Dept. of Human Services*

Other

Parent/Guardian (Primary)

First Middle Last

Lives with family?

Yes

Address

Street Address Address Line 2 City State ZIP Code

Mail Address (If different than living address)

Street Address Address Line 2 City State ZIP Code

Cell Phone

Work Phone

Home Phone

Prairie Five has permission to contact me via:

Text Message

Primary Email Address:

Birth Date

Gender

Male

Female

Social Security #(Required)

Marital Status

Single

Married

Divorced

Separated

Hispanic/Latino

Yes

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Highest Grade Completed

High School

GED

Grade 9 or less

Grade 10

Grade 11

No Education

Associate Degree

Bachelor's Degree

Graduate or Professional Degree

Current Employment Status

Full-Time

Part-Time

Seasonal

Unemployed

Retired/Disabled

Incarcerated

Parole/Probation

Relationship To Child

Parent

Grandparent

Foster Parent

Aunt/Uncle

Other

Currently Enrolled In School

Yes

Custody

Yes

Provide Financial Support

Yes

Typical work/school schedule

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Usual hours at work/school

Parent/Guardian (Secondary)

First Middle Last

Lives with family?

Yes

Address

Street Address Address Line 2 City State ZIP Code

Mail Address (If different than living address)

Street Address Address Line 2 City State ZIP Code

Cell Phone

Work Phone

Home Phone

Prairie Five has permission to contact me via:

Text Message

Primary Email Address:

Birth Date

Gender

Male

Female

Social Security #(Required)

Marital Status

Single

Married

Divorced

Separated

Hispanic/Latino

Yes

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Highest Grade Completed

High School

GED

Grade 9 or less

Grade 10

Grade 11

No Education

Associate Degree

Bachelor's Degree

Graduate or Professional Degree

Current Employment Status

Full-Time

Part-Time

Seasonal

Unemployed

Retired/Disabled

Incarcerated

Parole/Probation

Relationship To Child

Parent

Grandparent

Foster Parent

Aunt/Uncle

Other

Currently Enrolled In School

Yes

Custody

Yes

Provide Financial Support

Yes

Typical work/school schedule

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Usual hours at work/school

ADDITIONAL Family & Household Members Living With Child (Do Not List Applicant, Parent 1 & Parent 2)

Is mom currently pregnant?

Yes

If YES, please indicate the mother’s expectant due date

ADDITIONAL Family & Household Member 1

Name

First Last

Birth Date

Social Security #(Required)

Gender

Male

Female

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Hispanic/Latino

Yes

Relationship To Child

ADDITIONAL Family & Household Member 2

Name

First Last

Birth Date

Social Security #(Required)

Gender

Male

Female

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Hispanic/Latino

Yes

Relationship To Child

ADDITIONAL Family & Household Member 3

Name

First Last

Birth Date

Social Security #(Required)

Gender

Male

Female

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Hispanic/Latino

Yes

Relationship To Child

ADDITIONAL Family & Household Member 4

Name

First Last

Birth Date

Social Security #(Required)

Gender

Male

Female

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Hispanic/Latino

Yes

Relationship To Child

ADDITIONAL Family & Household Member 5

Name

First Last

Birth Date

Social Security #(Required)

Gender

Male

Female

Race

White

American Indian

Asian

Black/African American

Multi/Bi-racial

Native Hawaiian/Other Pacific Islander

Hispanic/Latino

Yes

Relationship To Child

Family Information

How did you hear about Prairie Five Head Start?

Returning family

Family/friend

Newspaper

Facebook

Radio

Prairie Five website

Other

Active Military Family?

Yes

Homeless Family?

Yes

Referred by Child Welfare Agency?

Yes

Receiving SNAP?

Yes

Receiving WIC?

Yes

Parent/Guardian(s) are currently a Prairie Five employee

Yes

Section (Does your child have a current/active IEP or IFSP?)

Does your child have a current/active IEP or IFSP?

Yes

If Yes, who provides your child with services?

What is your child’s primary disability or special need area?

Does your child have other disabilities/special needs areas?

Section Does your child have any developmental problems? (Ex: Speech, social, emotional)

Does your child have any developmental problems? (Ex: Speech, social, emotional)

Yes

If Yes, please list:

Section Do you have any concerns about your child’s emotional development?

Do you have any concerns about your child’s emotional development?

Yes

If Yes, please list:

Section Are you concerned about celebrating any holidays due to religious or ethnic beliefs

Are you concerned about celebrating any holidays due to religious or ethnic beliefs?

Yes

If Yes, please list:

Has your child attended preschool and/or daycare?

Yes

In Case Of An Emergency List Two Local Contacts, WITHIN 30 MILES of DISTRICT, If Parents Are Not Available. MUST List Two People Who Are NOT the Child’s Parents (REQUIRED-CANNOT BE LEFT BLANK)

Name (Contact #1)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relation To Child

Name (Contact #2)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relation To Child

Child Pickup Authorization

Name (1)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relation To Child

Name (2)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relation To Child

Name (3)

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relation To Child

UNAUTHORIZED Child Pickup . (Legal documentation and a photo of person are required)

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Relation To Child

Please complete the following Health & Wellness/Authorization sections as your application will not be considered complete if not filled out. If you have not brought your child to the dentist yet, please put down an emergency dental office. Please attach or send a copy of your child’s last well child checkup.

Health & Wellness

Child’s Primary Medical Home Clinic Name (required)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Has your child been seen at this clinic?

Yes

When was their last visit?

Child’s Health Insurance

Private

Blue Plus

Medical Assistance

No Insurance

Child’s Primary Dental Home Dental Office Name (required)

Address

Street Address Address Line 2 City State ZIP Code

Phone

Has your child been seen at this clinic?

Yes

When was their last visit?

Child’s Dental Insurance

Private

Blue Plus

Medical Assistance

No Insurance

Does your child have any current or chronic medical conditions? (Ex: Seizures, diabetes, asthma, heart problems, hearing (tubes/hearing aids), vision (glasses) etc.?)

Yes

If Yes, please list

Is your child currently taking any medications? If yes, please list if child need to take these medications during school hours.

Yes

If Yes, please list

Do you have any concerns about your child’s physical or mental development?

Yes

If Yes, please list

Has your child, or anyone in your household, been a victim of domestic or sexual abuse?

Yes

If Yes, please list

Has your child, or anyone in your household, been diagnosed with a disability/mental health or substance abuse?

Yes

If Yes, please list

Has the child had an immediate family member that has died?

Yes

If Yes, please list

Does your child have any allergies to food or medications? *If your child has any known allergies you are required to have an allergy documentation form completed by your health care provider*

Yes

If Yes, please list

Is your child currently up to date on their immunizations?

Yes

If No, please list

What is your primary source of water?

City

Private Well

Rural Water

Other

Unknown

Does your child receive fluoride from any of the following sources:

Tablets

Drops

Vitamins

Toothpaste

Mouth rinse

Topical Treatment from Dentist