Form Center

2. East Baton Rouge Parish Early Head Start Program
   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
   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
    Baton Rouge, LA 70805
    Phone: 225-806-6023
    Ages: 18 months-2 years
11. Children's Early Head Start
    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
    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
    - 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
    (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
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
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.
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

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