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Early Head Start Program Application

  1. East Baton Rouge Parish Early Head Start Program

    4523 Plank Road
    Baton Rouge, Louisiana 70805
    Phone: 225-358-4504
    Intake Section: 225-358-1964

  2. 2017 Application

  3. A Tradition of Excellence

    Early Childhood Education - Community Partnership / Volunteerism
    Nutritious Meals and Snacks - Comprehensive Child and Family Development Services
    Medical and Dental Services - Social Services for Families
    Activities for Parents - Assistance for Children with Special Needs

  4. Center Locations

  5. Capital Area Early Head Start

    3250 N Acadian Thruway E
    Baton Rouge, LA 70805
    Phone: 225-806-6023
    Ages: 18 months-2 years

  6. Children's Early Head Start

    7200 Maplewood Street
    Baton Rouge, LA 70812
    Phone: 225-355-9776
    Pregnant Women and ages 6 months-2 years

  7. Discovery Early Head Start

    9700 Scenic Highway
    Baton Rouge, LA 70807
    Phone: 225-775-7719
    Ages: 6 months-2 years

  8. The following information must be submitted with your application:

    - Applicant’s Birth Certificate/Verification of Birth
    - Applicant’s Immunization Card (up-to-date)
    - Notarized proof of guardianship (if applicable)
    - Social Security Cards for each family member - Applicant’s Medical Card or Health Insurance Card
    - Verification of Disability (if applicable)
    - Proof of Income: Relevant Time Period*
    - Payroll Check Stub (Must have name of company, name of employee, year to date income, hourly pay, pay period) within “Relevant Time Period”
    - All W2’s for “Relevant Time Period”
    - Income Tax Return – 1040 (preceding year)
    - Budget Slip
    - Social Security Statement
    - Social Security Income (SSI) Statement
    - Child Support Documents
    - Unemployment Compensation
    - Self-employment Statement
    - Non-Income Verification or Self-Declaration and Third Party Agreement

  9. * Relevant Time Period

    (A) the 12 months preceding the month in which the application is submitted; or
    (B) during the calendar year preceding the calendar year in which the application is submitted, whichever more accurately reflects the needs of the family at the time of application

  10. An Equal Opportunity Program

    Federal Law Prohibits Discrimination Because of Race, Color, Religion, Sex, Age, National Origin, and/or Special Needs

  11. Center applying for

  12. Expectant Mother's Information

  13. Parent's Information

  14. Relationship to Child

  15. Race / Ethnicity (Optional)

  16. Parent's Marital Status

  17. Child lives with?

  18. Child's Information

  19. Gender

  20. Race / Ethnicity (Optional)

  21. Language Spoken at Home:

  22. Child's Health Information

    Submit copy of Health Insurance Card

  23. Health Insurance

  24. Emergency Contacts

  25. In case of emergency contact:

  26. In addition to Emergency Contact, child may be released to:

  27. Medical Conditions / Disabilities

    Submit copy of medical reports / IFSP relating to Conditions

  28. Family Information

  29. Living Arrangement

  30. Housing

  31. Has family moved 2 or more times in the last 12 months?

  32. Transportation

  33. Maternal Relationship

  34. Relationship

  35. Race / Ethnicity

  36. Language:

  37. Education

  38. Employment

  39. Unemployed

  40. Other Public Assistance

  41. Special Conditions / Concerns

  42. Medical Conditions / Disabilities

  43. Health Insurance

  44. Currently Pregnant

  45. Substance Abuse

  46. Physical Abuse

  47. Legal Issues

  48. Paternal Relationship

  49. Relationship

  50. Race / Ethnicity

  51. Language:

  52. Education

  53. Employment

  54. Unemployed

  55. Other Public Assistance

  56. Special Conditions / Concerns

  57. Medical Conditions / Disabilities

  58. Health Insurance

  59. Currently Pregnant

  60. Substance Abuse

  61. Physical Abuse

  62. Legal Issues

  63. Other Family Relationships

  64. Relationship

  65. Relationship

  66. Gender

  67. Gender

  68. Race / Ethnicity

    Optional

  69. Race / Ethnicity

    Optional

  70. Language:

  71. Language:

  72. Education

  73. Education

  74. Relationship

  75. Relationship

  76. Gender

  77. Gender

  78. Race / Ethnicity

    Optional

  79. Race / Ethnicity

    Optional

  80. Language:

  81. Language:

  82. Education

  83. Education

  84. Acknowledgement

    I certify that, to the best of my knowledge, the information provided in this application is true and accurate. I understand that if any of this information changes or is found to be incorrect, I am obligated to notify this agency immediately. I understand that falsifying information such as family income, number of children, number of household members or relationship may result in the rejection of this application and my child being terminated from East Baton Rouge Parish Head Start/Early Head Start Program.

  85. Federal law prohibits discrimination because of race, color, religion, sex, age, national origin, and/or special needs.

  86. An Equal Opportunity Program

  87. Leave This Blank: