Application For Services English Application Application for Services Step 1 of 3 33% Program* Head Start Weatherization IDA Name* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address (if different from mailing address) Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* Phone - Home*Phone - Alternate/WorkEducation Level* 0 - 8 Non-Graduate 9 - 12 Non-Graduate High School Graduate/GED 12+ Some Secondary 2 Or 4 Year College Graduate Characteristics Homeless Farmer Migrant Farmer Seasonal Farm Worker Pregnant Youth Disabled Primary language spoken in the home* Family Type* Single Parent/Female Single Parent/Male 2 - Parent Home Single Person 2 - Adult/No-Children Home Other Family Type*12345678 or moreHousing*OwnRentHomelessOtherHow much is your rent?Rent FrequencyMonthWeekDayAre utilities included in your rent?YesNoDoes anyone in the household receive?CHECK ALL THAT APPLY. No Income Social Security SSI Benefits VA Benefits TEA/TANF Food Stamps Free/Reduced Lunch WIC ARKIDS Medicaid/Medicare Unemployment Benefits Pension/Retirement Employment Only Employment + any other Child Support Proof of Birth (Head Start & ABC) Others Household MembersNameGenderRaceSocial Security NumberDate of BirthEducation LevelAmount of Income Per MonthDisabilityVeteran Y/NHealth Insurance Y/N I understand that disclosure of my Social Security Number is voluntary and will be used for identification purposes. I certify that the above information is true and correct. This information will be kept strictly confidential unless its release is authorized in writing. General statistical information will be compiled with other households to create a report for funding sources.Applicant Signature 107.122.97.50 09/21/2023 Mozilla/5.0 (Linux; Android 10; K) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/117.0.0.0 Mobile Safari/537.36 QuestionaireIf child is/or was previously enrolled in an early childhood program, indicate program name and enrollment dates. Name of Program Enrollment Dates (From - To) Does the family need childcare for preschool or school aged children?Preschool aged?YesNoIf yes, check one: Full Time (8 hours) Part Time (6 hours or less) School aged?YesNoIf yes, check one: Full Time (8 hours) Part Time (6 hours or less) Does the family wish to enroll their preschool aged children for developmental (social-emotional, cognitive, physical) reasons or school readiness?YesNoIf Yes, ages of children If family enrolled in Head Start, which would be the Head Start Program Option preference?Center Base (At Head Start Center)Home Base (Home visitor makes weekly visits to the home)If Center Base, can family transport child to Head Start Center?YesNoEnvironmental RisksCheck all that apply. None Child in Welfare System Foster Child Grandparents Raising Child Extreme Medical Expenses Parents Incarcerated Death of Parent Serious Illness Loss of Home Inadequate Housing Loss of Job Referred from another agency?YesNoChild with Disabilities? Suspected Diagnosed Multi-Diagnosed Additional Phone NumbersDirections to HomeThis program adheres to all provisions of Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act (ADA) - Public Law 101-336. The Disabilities Coordinator is the designated person responsible for assurance of Section 504 and the ADA.Head of Household Employed School Pregnant Spouse/Other Employed School Pregnant FileMax. file size: 256 MB. Δ
