Form Center

Early Head Start Program Application

2. East Baton Rouge Parish Early Head Start Program
   4523 Plank Road <br> Baton Rouge, Louisiana 70805 <br> Phone: 225-358-4504 <br> Intake Section: 225-358-1964

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

4. 2017 Application

6. A Tradition of Excellence
   Early Childhood Education - Community Partnership / Volunteerism <br> Nutritious Meals and Snacks - Comprehensive Child and Family Development Services <br> Medical and Dental Services - Social Services for Families <br> Activities for Parents - Assistance for Children with Special Needs

   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

8. Center Locations

10. Capital Area Early Head Start
    3250 N Acadian Thruway E <br> Baton Rouge, LA 70805 <br> Phone: 225-806-6023 <br> Ages: 18 months-2 years

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

11. Children's Early Head Start
    7200 Maplewood Street <br> Baton Rouge, LA 70812 <br> Phone: 225-355-9776 <br> Pregnant Women and ages 6 months-2 years

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

12. Discovery Early Head Start
    9700 Scenic Highway <br> Baton Rouge, LA 70807 <br> Phone: 225-775-7719 <br> Ages: 6 months-2 years

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

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

    - 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

16. * Relevant Time Period
    (A) the 12 months preceding the month in which the application is submitted; or <br> (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

    (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

18. An Equal Opportunity Program
    Federal Law Prohibits Discrimination Because of Race, Color, Religion, Sex, Age, National Origin, and/or Special Needs

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

19. Today's Date
    Today's Date

21. Center applying for

    1. Children's World
    2. Capital Area
    3. Discovery

22. Referring Agency

23. Contact Person

24. Contact Person Phone Number

28. Expectant Mother's Information

30. Expectant Mother's Name

31. Anticipated Date of Delivery
    Anticipated Date of Delivery

33. Prenatal Physician

34. Address of Physician

36. Phone Number

38. Parent's Information

40. Parent / Guardian's Name

41. Date of Birth
    Date of Birth

42. Relationship to Child

    1. Mother
    2. Father
    3. Grandparent
    4. Other

44. Social Security Number

45. Race / Ethnicity (Optional)

    1. African American / Black
    2. Asian
    3. Caucasian / White

    1. Hispanic / Latino
    2. Other

47. If other, explain.

49. Address

50. City, State

51. Zip Code

53. Home Phone Number

54. Cell Phone Number

56. Place of Employment

57. Work Phone

59. Parent's Marital Status

    1. Single
    2. Married

    1. Divorced
    2. Separated

60. Child lives with?

    1. Mother
    2. Father

    1. Legal Guardian

64. Child's Information

66. Child's Name

67. Date of Birth
    Date of Birth

68. Age

70. Social Security Number

71. Gender

    1. Male
    2. Female

72. Race / Ethnicity (Optional)

    1. African American / Black
    2. Asian
    3. Caucasian / White
    4. Hispanic / Latino
    5. Native American / Alaskan
    6. Other

74. If other, explain.

76. Language Spoken at Home:

77. Primary

78. Secondary

82. Child's Health Information
    Submit copy of Health Insurance Card

    Submit copy of Health Insurance Card

84. Health Insurance

    1. No Health Insurance
    2. LaCHIP Number
    3. MEDICAID Number
    4. Health Insurance Company

85. LaCHIP Number

86. MEDICAID Number

88. Health Insurance Company

89. Policy Number

91. Primary Care Physician

92. Address

93. Phone Number

95. Dentist

96. Address

97. Phone Number

101. Emergency Contacts

103. In case of emergency contact:

     1. Certain Person
     2. Medical Personnel
     3. 9-1-1
     4. Share Medical Health Records

104. Name

105. Phone Number

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

109. Name

110. Home Phone Number

111. Cell Phone Number

113. Name

114. Home Phone Number

115. Cell Phone Number

117. Name

118. Home Phone Number

119. Cell Phone Number

121. Name

122. Home Phone Number

123. Cell Phone Number

125. Medical Conditions / Disabilities

     Submit copy of medical reports / IFSP relating to Conditions

     1. Allergies
     2. Birth Defects
     3. Diabetes
     4. Emotional / Behavior Disorder
     5. Health Impairment

     1. Visual Impairment / Blindness
     2. Autism
     3. Developmental Delay
     4. Dietary Restrictions
     5. Epilepsy / Seizures

     1. Hearing Impairment / Deafness
     2. Learning Disability
     3. Traumatic Brain Injury
     4. Speech / Language

     1. Sickle Cell Anemia
     2. Mental Retardation
     3. Orthopedic Impairment
     4. Other
127. Type

128. Type

129. Type

130. If other, explain.

134. Family Information

136. Living Arrangement

     1. Two Parents
     2. Single Parent - Mother Only
     3. Single Parent - Father Only

     1. Single Parent / Mother and Partner
     2. Single Parent / Father and Partner

     1. Legal Guardian
     2. Grandparent

138. Housing

     1. Own / Buying
     2. Renting House

     1. Apartment
     2. Homeless / Shelter

     1. Public Housing Assistance
     2. Other

140. How long at this address?

141. If other, explain.

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

     1. Yes
     2. No

145. Transportation

     1. Private Vehicle
     2. Public Transportation
     3. Friend / Relative
     4. Other

146. If other, explain.

148. Maternal Relationship

150. Relationship

     1. Mother

     1. Grandmother

     1. Legal Guardian

     1. Other

152. Name

153. Date of Birth
     Date of Birth

154. Age

156. Social Security Number

157. Race / Ethnicity

     1. African American / Black
     2. Asian
     3. Caucasian / White

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other

159. If other, explain.

161. Language:

162. Primary

163. Secondary

165. Education

     1. College / Advance Degree
     2. Associate Degree
     3. Some College

     1. High School Diploma / GED
     2. 12th Grade

     1. 11th Grade
     2. 10th Grade

     1. 9th Grade
     2. Less than 8th Grade

167. Employment

     1. Full-time
     2. Part-time

     1. Disabled

     1. In-School / Training

     1. Unemployed

169. Unemployed

     1. With Previous Experience
     2. With No Previous Experience

     1. Other

170. If other, explain.

172. Work Place

173. Work Place Phone Number

175. Other Public Assistance

     1. Medicaid / Medicare
     2. Food Stamps
     3. WIC

     1. Child Care Assistance
     2. Other

176. If other, explain.

178. Special Conditions / Concerns

180. Medical Conditions / Disabilities

     1. Yes
     2. No

181. If yes, describe

183. Health Insurance

     1. Yes
     2. No

184. Currently Pregnant

     1. Yes
     2. No

185. Substance Abuse

     1. Yes
     2. No

187. Physical Abuse

     1. Yes
     2. No

188. Legal Issues

     1. Yes
     2. No

192. Paternal Relationship

194. Relationship

     1. Father

     1. Grandfather

     1. Legal Guardian

     1. Other

196. Name

197. Date of Birth
     Date of Birth

198. Age

200. Social Security Number

201. Race / Ethnicity

     1. African American / Black
     2. Asian
     3. Caucasian / White

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other

203. If other, explain.

205. Language:

206. Primary

207. Secondary

209. Education

     1. College / Advance Degree
     2. Associate Degree
     3. Some College

     1. High School Diploma / GED
     2. 12th Grade

     1. 11th Grade
     2. 10th Grade

     1. 9th Grade
     2. Less than 8th Grade

211. Employment

     1. Full-time
     2. Part-time

     1. Disabled

     1. In-School / Training

     1. Unemployed

213. Unemployed

     1. With Previous Experience
     2. With No Previous Experience

     1. Other

214. If other, explain.

216. Work Place

217. Work Place Phone Number

219. Other Public Assistance

     1. Medicaid / Medicare
     2. Food Stamps
     3. WIC

     1. Child Care Assistance
     2. Other

220. If other, explain.

222. Special Conditions / Concerns

224. Medical Conditions / Disabilities

     1. Yes
     2. No

225. If yes, describe

227. Health Insurance

     1. Yes
     2. No

228. Currently Pregnant

     1. Yes
     2. No

229. Substance Abuse

     1. Yes
     2. No

231. Physical Abuse

     1. Yes
     2. No

232. Legal Issues

     1. Yes
     2. No

236. Other Family Relationships

238. Relationship

     1. Sibling

     1. Non-Relative

239. Relationship

     1. Sibling

     1. Non-Relative

241. Name

242. Name

244. Date of Birth
     Date of Birth

245. Age

246. Date of Birth
     Date of Birth

247. Age

249. Social Security Number

250. Social Security Number

252. Gender

     1. Male

     1. Female

253. Gender

     1. Male
     2. Female

255. Race / Ethnicity

     Optional

     1. African American / Black
     2. Asian
     3. Caucasian / White

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
256. Race / Ethnicity

     Optional

     1. African American / Black
     2. Asian
     3. Caucasian / White

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
258. If other, explain.

259. If other, explain.

261. Language:

262. Language:

264. Primary

265. Secondary

266. Primary

267. Secondary

269. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade

270. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade

272. Relationship

     1. Sibling

     1. Non-Relative

273. Relationship

     1. Sibling

     1. Non-Relative

275. Name

276. Name

278. Date of Birth
     Date of Birth

279. Age

280. Date of Birth
     Date of Birth

281. Age

283. Social Security Number

284. Social Security Number

286. Gender

     1. Male

     1. Female

287. Gender

     1. Male
     2. Female

289. Race / Ethnicity

     Optional

     1. African American / Black
     2. Asian
     3. Caucasian / White

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
290. Race / Ethnicity

     Optional

     1. African American / Black
     2. Asian
     3. Caucasian / White

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
292. If other, explain.

293. If other, explain.

295. Language:

296. Language:

298. Primary

299. Secondary

300. Primary

301. Secondary

303. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade

304. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade

308. 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.

     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.

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

312. Parent / Guardian's Name (Print)

314. Parent / Guardian's Signature

315. Date
     Date

317. An Equal Opportunity Program

Leave This Blank:


318. Print Only

* indicates a required field