HE HEAD START OF YAMHILL
COUNTY
PO BOX 1311;
MCMINNVILLE, OR 97128
503 472 2000
ENROLLMENT APPLICATION
Did an agency refer you to Head Start?
š No š Yes
Agency
Name/Person referred: ___________________________
Parent Information
Parent Name: ___________________________________________ Parent Date of Birth: ________________________
Parent Name: ___________________________________________ Parent Date of Birth: ________________________
Are
you pregnant? No Yes If yes, expected due date:____________________________
Home Address__________________________________ City ________________ State ___________ Zip ____________
Mailing Address _________________________________ City ________________ State___________ Zip ___________
Address where child will be coming to/from Head Start:_____________________________________________________
Own
Home Rent Home Living with others or
homeless-Explain:____________________________
Home Phone ______________________ Cell Phone ___________________ Message Phone_____________________
2 2 Parent household 1
Parent household 2
Grandparent household 1
Grandparent household Foster Parent
Parent
Education: Lacks High School
Diploma or GED High School Diploma/GED Attending School
Need help filling out form Either child or parent does not
speak English
Child/Children Information
Head
Start Child’s Name: _______________________________ Child Date of Birth: _____________ Male
Female
Head
Start Child’s Name: _______________________________ Child Date of Birth: _____________ Male
Female
Does
your child have a diagnosed disability? No Yes Date of diagnosis:
_________________________
Is
this child on an IFSP? No Yes Family member diagnosed with a
disability? No Yes
Number
of people in family: ______________ Ages of
other children in the home: _____________________________
Income Information
Include all income from wages, DHS, Social Security (SSI) Unemployment Compensation, Workers Compensation, alimony, child support etc.
ATTACH
COPIES OF PROOF OF INCOME. Copies of
last year’s federal income tax return or copies of all W-2 forms from previous
tax year or copies of all
pay stubs for last 12 consecutive months.
____________ TANF assistance from DHS. Please list what benefits you receive and complete the DHS release at the
bottom of the page: __________________________________________________________________
$____________ Gross Yearly Income from Wages
$____________ Gross Yearly Income – Other Sources ____________________________________________________
Please
list source e.g. Child Support, SSI, Alimony, Unemployment, Worker Comp. etc
$ ___________ Total Gross Yearly
Income
The above information is true
and complete to the best of my knowledge
_______________________________________________ __________________
Parent/Guardian Signature Date
DHS RELEASE CASE WORKER’S NAME: _________________________________________ I give permission for
Head Start of Yamhill County to obtain income information from the
Department of Human Services ________________________________________ ___________________________ ________________ Parent/Guardian Signature Social
Security Number Date
Do you have a child
who will be 3 or 4 years old
by September 1?
Head Start of Yamhill County offers a variety of programs for preschool age children!
10% of
enrollment slots are made available to children with disabilities!
SIGN UP NOW!
LIMITED NUMBER OF SLOTS!!
HEAD START OF YAMHILL COUNTY
2045 SW Hwy 18,
MCMINNVILLE, OR
97128
Questions? Call (503) 472-2000
*Applications
accepted all year*