 | Application for the
Enfield Public Schools Head Start Program
at the Stowe Early Learning Center 117 Post Office Road, Enfield, CT | .png) |
Date: (MO/DY/YEAR)
Child’s Legal Name (must match birth certificate):
(First name) (Middle name) (Last name)
Nickname:
Date of Birth: (MO/DY/YEAR)
Who is submitting this application: Mother Father Both Guardian
Who does child live with?: Mother Father Both Guardian
Marital Status: Married Single Divorced Widowed
Address:
Phone (xxx-xxx-xxxx) :
Email:
How long have you lived in Enfield?
Where did you reside prior?
Country of Origin:
Race:
Gender: Male Female
Language(s) spoken at home?
If foster child, name of the state worker:
Is there a surrogate parent assigned? Yes No If yes, name:
Number of person(s) in home:
Household Information
Children in Home
Has your child been diagnosed with a disability or received services from Birth to Three? Yes No
If Yes, what was the diagnosis:
Services received:
Does any person listed above have any health problems? Yes No
If yes, describe:
Referred to program? Yes No By Whom?
Has your child had any pre-school or childcare experience? Yes No
If yes, where:
Have you had any children the Head Start program in the past? Yes No
Are you receiving any state benefits? Yes No
If Yes, What benefits are you receiving?
Are there any specific family needs or crisis? Yes No
If yes, please describe:
Income: List by family member:
Yearly GROSS income by family $
Verified by (staff member)
Type of verification:
Certification: I certify that this information is true. If any part is false, my participation in this agency’s program 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.
Signature of parent or guardian _______________________________ Date ___________________
Signature of staff member ________________________________ Date ___________________
You may also drop this form off to the front desk at Stowe Early Learning Center.
Be sure to click on the submit button below(only once).
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