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Early Head Start Program Application
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East Baton Rouge Parish Early Head Start Program
4523 Plank Road
Baton Rouge, Louisiana 70805
Phone: 225-358-4504
Intake Section: 225-358-1964
2017 Application
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
Center Locations
Capital Area Early Head Start
3250 N Acadian Thruway E
Baton Rouge, LA 70805
Phone: 225-806-6023
Ages: 18 months-2 years
Children's Early Head Start
7200 Maplewood Street
Baton Rouge, LA 70812
Phone: 225-355-9776
Pregnant Women and ages 6 months-2 years
Discovery Early Head Start
9700 Scenic Highway
Baton Rouge, LA 70807
Phone: 225-775-7719
Ages: 6 months-2 years
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
* 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
An Equal Opportunity Program
Federal Law Prohibits Discrimination Because of Race, Color, Religion, Sex, Age, National Origin, and/or Special Needs
Today's Date
Today's Date
Center applying for
Children's World
Capital Area
Discovery
Referring Agency
Contact Person
Contact Person Phone Number
Expectant Mother's Information
Expectant Mother's Name
Anticipated Date of Delivery
Anticipated Date of Delivery
Prenatal Physician
Address of Physician
Phone Number
Parent's Information
Parent / Guardian's Name
Date of Birth
Date of Birth
Relationship to Child
Mother
Father
Grandparent
Other
Social Security Number
Race / Ethnicity (Optional)
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Other
If other, explain.
Address
City, State
Zip Code
Home Phone Number
Cell Phone Number
Place of Employment
Work Phone
Parent's Marital Status
Single
Married
Divorced
Separated
Child lives with?
Mother
Father
Legal Guardian
Child's Information
Child's Name
Date of Birth
Date of Birth
Age
Social Security Number
Gender
Male
Female
Race / Ethnicity (Optional)
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Native American / Alaskan
Other
If other, explain.
Language Spoken at Home:
Primary
Secondary
Child's Health Information
Submit copy of Health Insurance Card
Health Insurance
No Health Insurance
LaCHIP Number
MEDICAID Number
Health Insurance Company
LaCHIP Number
MEDICAID Number
Health Insurance Company
Policy Number
Primary Care Physician
Address
Phone Number
Dentist
Address
Phone Number
Emergency Contacts
In case of emergency contact:
Certain Person
Medical Personnel
9-1-1
Share Medical Health Records
Name
Phone Number
In addition to Emergency Contact, child may be released to:
Name
Home Phone Number
Cell Phone Number
Name
Home Phone Number
Cell Phone Number
Name
Home Phone Number
Cell Phone Number
Name
Home Phone Number
Cell Phone Number
Medical Conditions / Disabilities
Submit copy of medical reports / IFSP relating to Conditions
Allergies
Birth Defects
Diabetes
Emotional / Behavior Disorder
Health Impairment
Visual Impairment / Blindness
Autism
Developmental Delay
Dietary Restrictions
Epilepsy / Seizures
Hearing Impairment / Deafness
Learning Disability
Traumatic Brain Injury
Speech / Language
Sickle Cell Anemia
Mental Retardation
Orthopedic Impairment
Other
Type
Type
Type
If other, explain.
Family Information
Living Arrangement
Two Parents
Single Parent - Mother Only
Single Parent - Father Only
Single Parent / Mother and Partner
Single Parent / Father and Partner
Legal Guardian
Grandparent
Housing
Own / Buying
Renting House
Apartment
Homeless / Shelter
Public Housing Assistance
Other
How long at this address?
If other, explain.
Has family moved 2 or more times in the last 12 months?
Yes
No
Transportation
Private Vehicle
Public Transportation
Friend / Relative
Other
If other, explain.
Maternal Relationship
Relationship
Mother
Grandmother
Legal Guardian
Other
Name
Date of Birth
Date of Birth
Age
Social Security Number
Race / Ethnicity
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Native American / Alaskan
Other
If other, explain.
Language:
Primary
Secondary
Education
College / Advance Degree
Associate Degree
Some College
High School Diploma / GED
12th Grade
11th Grade
10th Grade
9th Grade
Less than 8th Grade
Employment
Full-time
Part-time
Disabled
In-School / Training
Unemployed
Unemployed
With Previous Experience
With No Previous Experience
Other
If other, explain.
Work Place
Work Place Phone Number
Other Public Assistance
Medicaid / Medicare
Food Stamps
WIC
Child Care Assistance
Other
If other, explain.
Special Conditions / Concerns
Medical Conditions / Disabilities
Yes
No
If yes, describe
Health Insurance
Yes
No
Currently Pregnant
Yes
No
Substance Abuse
Yes
No
Physical Abuse
Yes
No
Legal Issues
Yes
No
Paternal Relationship
Relationship
Father
Grandfather
Legal Guardian
Other
Name
Date of Birth
Date of Birth
Age
Social Security Number
Race / Ethnicity
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Native American / Alaskan
Other
If other, explain.
Language:
Primary
Secondary
Education
College / Advance Degree
Associate Degree
Some College
High School Diploma / GED
12th Grade
11th Grade
10th Grade
9th Grade
Less than 8th Grade
Employment
Full-time
Part-time
Disabled
In-School / Training
Unemployed
Unemployed
With Previous Experience
With No Previous Experience
Other
If other, explain.
Work Place
Work Place Phone Number
Other Public Assistance
Medicaid / Medicare
Food Stamps
WIC
Child Care Assistance
Other
If other, explain.
Special Conditions / Concerns
Medical Conditions / Disabilities
Yes
No
If yes, describe
Health Insurance
Yes
No
Currently Pregnant
Yes
No
Substance Abuse
Yes
No
Physical Abuse
Yes
No
Legal Issues
Yes
No
Other Family Relationships
Relationship
Sibling
Non-Relative
Relationship
Sibling
Non-Relative
Name
Name
Date of Birth
Date of Birth
Age
Date of Birth
Date of Birth
Age
Social Security Number
Social Security Number
Gender
Male
Female
Gender
Male
Female
Race / Ethnicity
Optional
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Native American / Alaskan
Other
Race / Ethnicity
Optional
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Native American / Alaskan
Other
If other, explain.
If other, explain.
Language:
Language:
Primary
Secondary
Primary
Secondary
Education
Some College
High School Diploma / GED
Less than 12th Grade
Education
Some College
High School Diploma / GED
Less than 12th Grade
Relationship
Sibling
Non-Relative
Relationship
Sibling
Non-Relative
Name
Name
Date of Birth
Date of Birth
Age
Date of Birth
Date of Birth
Age
Social Security Number
Social Security Number
Gender
Male
Female
Gender
Male
Female
Race / Ethnicity
Optional
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Native American / Alaskan
Other
Race / Ethnicity
Optional
African American / Black
Asian
Caucasian / White
Hispanic / Latino
Native American / Alaskan
Other
If other, explain.
If other, explain.
Language:
Language:
Primary
Secondary
Primary
Secondary
Education
Some College
High School Diploma / GED
Less than 12th Grade
Education
Some College
High School Diploma / GED
Less than 12th Grade
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.
Federal law prohibits discrimination because of race, color, religion, sex, age, national origin, and/or special needs.
Parent / Guardian's Name (Print)
Parent / Guardian's Signature
Date
Date
An Equal Opportunity Program
Leave This Blank:
Print Only
* indicates a required field
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