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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
  69. Race / Ethnicity
  70. Language:
  71. Language:
  72. Education
  73. Education
  74. Relationship
  75. Relationship
  76. Gender
  77. Gender
  78. Race / Ethnicity
  79. Race / Ethnicity
  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: