Lincoln Head Start Child Development Program

This application must be completed and all documentation submitted before it is considered for enrollment. Documents such as

Birth certificates

Shot Records

Proof Of Income

Food Stamp Printout

Disability Documentation

And Homeless Verification ( You May Qualify if you and your child live with other families)

Gaurdian Name *

Childs Name *

Date of birth *

Sex

Male

Female

Family Information ( Only include members in the household supported by the income of the parent)

Full Name

Relationship

MONTHLY INCOME

SOUCE OF INCOME

Address

City

Zip Code *

Email *

Phone *

EMERGENCY PHONE NUMBER *

CHILD RACE *

BLACK

WHITE

HISPANIC

BIRACIAL/MULTI

LATINO

CHILD LIVES WITH, ANSWER YES BELOW

BOTH PARENTS

MOTHER

FATHER

GRANDPARENTS

FOSTER PARENTS

ELIGIBILITY INFORMATION (DOES THE FAMILY RECEIVE) *

FOOD STAMPS

SSI

TANF

OTHER

Children with special needs may receive priority for enrollment. Disclosure of this information is strictly voluntary.

Children with special needs may receive priority for enrollment. Disclosure of this information is strictly voluntary

YES

WHAT TYPE

Does the child have an IEP/IFSP? *

YES

Does the child receive special services? *

YES

Is your child served by Early Steps? *

YES

Is your child overactive or aggressive? *

YES

Do you feel that your child has a special need that has not been diagnosed? 14w2r

YES

If yes please explain

UPLOAD BIRTH CERTIFICATE *

UPLOAD PROOF OF INCOME *

UPLOAD DISABILITY DOCUMENTATION

FOOD STAMP PRINTOUT

CERTIFICATION STATEMENT

I certify that the above information is true and that all income is reported. I also agree to comply with the rules

and regulations of the Head Start Program to the best of my ability.

ParentsGuardians Signature *

Clear