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2009 Eligibility Application Copa 4 2009

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2009 Eligibility Application Copa 4 2009

  1. 1. Enrollment Year________ Center ID # __________ TELAMON CORPORATION MIGRANT & SEASONAL HEAD START APPLICATION Complete one copy per family PRIMARY CAREGIVER INFORMATION 1. First Name_________________________ M. Initial:_____ Last Name_____________________________________ 2. Gender: __________ 3. *Application Date: ________________ 4. *Date of Birth:____________________________ 5. TANF #__________________________ 6. *Receiving WIC:  Yes  No  Previously 7. *Which language do you speak (primary)?  English  Spanish  Native Central or South American/Mexican  Caribbean  Pacific Island  Native North American or Alaska Native  European/Slavic  African  Middle Eastern/South Asian  East Asian  Unspecified  Other (Specify):______________________________ 8. *Which language do you speak (secondary)? (Choose from above list and write in here)________________________ 9. *Ethnicity:  Hispanic  Non-Hispanic 10. *Race:  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian/Pacific Islander  White  Bi-Racial/Multi-Racial  Unspecified  Other (Specify):_____________________________________ 11. *What is your highest level of education?  Less than high shool graduate  High School Graduate/GED Some college, vocational school or Associate degree  Bachelor or advanced degree 12. *What is your employment status?  Employed  In job training or school  Not working  Both working and in training/school 13. What is your employer’s or school’s name:__________________________________________________________ 14. What are your phone numbers? Home:___________________________________________________________ Mobile:_________________________________________ Work:____________________________________ 15. What is your local address? StreetAddress:_____________________________________________________________________________ City:______________________________ State:________Zip Code:_____________County:______________ 16. What is your mailing address (if different from above) (note: data entry as “other”): StreetAddress:_____________________________________________________________________________ City:______________________________ State:________Zip Code:_____________ 17. *Number in family: _______Adults _________Children __________ Total 18. *Number in household __________ 19. Are you disabled?  Yes  No 20. *Do you have medical insurance?  Yes  No If yes, specify type: ____________________________________ 21. Are you pregnant?  Yes  No If yes, specify due date: ______________________________________
  2. 2. Enrollment Year________ Center ID # __________ Family Name________________________________ 22. *What is your current housing?  Homeless  Own  Rent  Other_______________________________ *Date you began living in your current housing?__________________________________________________ 23. *What was your previous housing?  Homeless  Own Rent  Other_______________________________ 24. Have you and your family moved in the last 24 months?  Yes  No 25. What type of housing are you currently in?  Apartment  House  Duplex  Mobile Home  Other____________________ 26. What is the cost for your current housing? $_____________________ 27. Family Type:  Single Parent/Female  Single Parent/Male  Two Parent  Other________________ 28. Do you receive:  HEAP  Food Stamps SECONDARY CAREGIVER INFORMATION  No secondary caregiver (skip to income information section) 1. First Name_________________________ M. Initial:_____ Last Name_____________________________________ 2. Gender: __________ 3. *Application Date: ___________________ 4. *Date of Birth:________________________ 5. TANF #_________________________ 6. *Receiving WIC:  Yes  No  Previously 7. *Which language do you speak (primary)?  English  Spanish  Native Central or South American/Mexican  Caribbean  Pacific Island  Native North American or Alaska Native  European/Slavic  African  Middle Eastern/South Asian  East Asian  Unspecified  Other (Specify):______________________________ 8. *Which language do you speak (secondary)? (Choose from above list and write in here)________________________ 9. *Ethnicity:  Hispanic  Non-Hispanic 10. *Race:  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian/Pacific Islander  White  Bi-Racial/Multi-Racial  Unspecified  Other (Specify):_____________________________________ 11. *What is your highest level of education?  Less than high shool graduate  High School Graduate/GED Some college, vocational school or Associate degree  Bachelor or advanced degree 12. *What is your employment status?  Employed  In job training or school  Not working  Both working and in training/school 13. What is your employer’s or school’s name:__________________________________________________________ 14. What are your phone numbers? Home:_______________________________________________________ Mobile:________________________________________ Work:_____________________________________ 15. What is your local address? StreetAddress:_____________________________________________________________________________ City:___________________________ State:_________Zip Code:_____________County:________________ 16. What is your mailing address (if different from above) (note: data entry as “other”): StreetAddress:_____________________________________________________________________________ City:___________________________ State:_________Zip Code:_____________
  3. 3. Enrollment Year________ Center ID # __________ Family Name________________________________ 17. *Number in family: _______Adults _________Children __________ Total 18. *Number in household __________ 19. Are you disabled?  Yes  No 20. *Do you have medical insurance?  Yes  No If yes, specify type: __________________________________ 21. Are you pregnant?  Yes  No If yes, specify due date: ______________________________________
  4. 4. Enrollment Year________ Center ID # __________ Family Name________________________________ CAREGIVER INCOME INFORMATION (Transfer summary information from income work history) Income Primary Caregiver Secondary Caregiver Employment $ /Year $ /Year Child Support $ /Year $ /Year SSI $ /Year $ /Year TANF $ /Year $ /Year Unemployment $ /Year $ /Year College Grants & Scholarships $ /Year $ /Year Social Security $ /Year $ /Year Other ____________ $ /Year $ /Year  No Income  Receives SSI  Receives TANF Income Comments: 1. Is the family’s Primary Income Source agricultural work (based on last 12months’ income)? / Yes (Skip to # 3) No (Go to # 2) 2. Does the First-Time Migrant Worksheet show that the family has verified first-time migrant status? N/A Yes (include the Worksheet behind this application in the family’s file). No (Family is Ineligible for services – End of Intake) 3. Is the family currently working in agriculture? Yes (skip to #5) No (go to #4) 4. If the family is not currently working in agriculture, do they plan to work in agriculture while their child(ren) are enrolled in MSHS? Yes If yes, when and for whom? ___________________________________________________ NOTE: They must provide evidence of current work in agriculture once they start working. No (Family is Ineligible for services – End of Intake) 5. Did the family move within the last 2 years for the purpose of seeking agricultural employment Yes, specify type of move Interstate Intrastate _____Number of moves for purpose of agricultural work within the past 24 months First-Time Migrant (Must verify low-income for 52 weeks) No (end of intake for MI) No, however family qualifies as Seasonal Farm Worker (TN only)
  5. 5. Enrollment Year________ Center ID # __________ Family Name________________________________ CHILD APPLICATION (Complete one for each age eligible child in family along with a Priority Point Sheet) 1. First Name_____________________ M. Initial:_____ Last Name_________________________ 2. Gender: __________ 3.*Application Date: _____________ 4. *Date of Birth:_________________ 7. *Which language does your child speak (primary)?  Not yet speaking  English  Spanish  Native Central or South American/Mexican  Caribbean  Pacific Island  Native North American or Alaska Native  European/Slavic  African  Middle Eastern/South Asian  East Asian  Unspecified  Other (Specify):______________________ 8. *Which language does your child speak (secondary)? (choose from above list and write in here)________ 9. Is English spoken at home?  Yes  No 10. How would you rate your child’s English skills?  Very Well  Well  Not Well  Not at all 9. *Child’s Ethnicity:  Hispanic  Non-Hispanic 10. *Child’s Race:  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian/Pacific Islander  White  Bi-Racial/Multi-Racial  Unspecified  Other (Specify):_______________________ 11. *Does your child have a disability?  Yes  No If yes:  Disability evaluation in progress  IEP/IFSP  Other (Specify):_______________________________________________ 12. How many years has your child been enrolled in this Migrant Head Start program?___________ 13. *This child needs:  Full time child care  Part time child care  Evening child care  Overnight child care  Weekend child care  *Child is receiving a child care subsidy/voucher *Secondary source of child care (outside of Head Start):  Family child care home  Child care center (other than Head Start)  At home or at another home with a relative or unrelated adult  Public school pre-kindergarten program  Other(specify):__________________________________________________________ 14. *Did this child receive services before classes began this season?  Yes  No 15. *Child’s father/father figure participates in regularly scheduled program activities  Yes  No 16. Child has a medical card:  Yes  No
  6. 6. Enrollment Year________ Center ID # __________ Family Name________________________________ FAMILY USER DEFINED QUESTIONS: 1. Does this family need a translator?  Yes  No 2. List name/age/gender of other siblings in family: Name _______________ AGE ______ Male Female Name ______________ AGE ______ Male Female Name _______________ AGE ______ Male Female Name ______________ AGE ______ Male Female Name ______________ AGE ______ Male Female Name ______________ AGE ______ Male Female 3. What is the family’s “home based” address and phone number: Address_________________________________________________________________________________ City_______________________________________ State_________________ Zip Code_______________ Phone number:______________________________________________ County:______________________ The information provided here is true to the best of my knowledge. I understand that this information is subject to review and verification and that this includes providing documents or employer confirmation to support it. I further understand that my child(ren) may be terminated from the program if found ineligible. I have read and understood the above or had it explained to me. I have been advised about Telamon’s eligibility and the program’s complaint procedures. Según mi leal pensar y saber la información proveída está correcta. Entiendo que esta información estará sujeta a revisión y verificación y me doy cuenta de que me pueden pedir que yo provea la verificación para apoyar estos datos. Yo entiendo que mi/s niño/s pueden ser descalificados inmediatamente si no me encuentran eligible. Yo he leído y entendido todo lo anteriormente citado, o me lo han explicado. También me han explicado la política de Telamon sobre la elegibilidad de familias para Head Start y el procedimiento de quejas y apelaciones. Parent Signature: _____________________________________________ Date:______/_______/______ Staff Signature:_______________________________________________ Date:_____/_______/_______
  7. 7. Enrollment Year________ Center ID # __________ Family Name________________________________ FAMILY USER DEFINED QUESTIONS: 1. Does this family need a translator?  Yes  No 2. List name/age/gender of other siblings in family: Name _______________ AGE ______ Male Female Name ______________ AGE ______ Male Female Name _______________ AGE ______ Male Female Name ______________ AGE ______ Male Female Name ______________ AGE ______ Male Female Name ______________ AGE ______ Male Female 3. What is the family’s “home based” address and phone number: Address_________________________________________________________________________________ City_______________________________________ State_________________ Zip Code_______________ Phone number:______________________________________________ County:______________________ The information provided here is true to the best of my knowledge. I understand that this information is subject to review and verification and that this includes providing documents or employer confirmation to support it. I further understand that my child(ren) may be terminated from the program if found ineligible. I have read and understood the above or had it explained to me. I have been advised about Telamon’s eligibility and the program’s complaint procedures. Según mi leal pensar y saber la información proveída está correcta. Entiendo que esta información estará sujeta a revisión y verificación y me doy cuenta de que me pueden pedir que yo provea la verificación para apoyar estos datos. Yo entiendo que mi/s niño/s pueden ser descalificados inmediatamente si no me encuentran eligible. Yo he leído y entendido todo lo anteriormente citado, o me lo han explicado. También me han explicado la política de Telamon sobre la elegibilidad de familias para Head Start y el procedimiento de quejas y apelaciones. Parent Signature: _____________________________________________ Date:______/_______/______ Staff Signature:_______________________________________________ Date:_____/_______/_______

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