Form Center

2. East Baton Rouge Parish Head Start Program
   4523 Plank Road
   Baton Rouge, Louisiana 70805
   Phone: 225-358-4504
   Intake Section: 225-358-1964
4. 2017 - 2018 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
    
11. Charlie Thomas Head Start Center
    8686 Pecan Tree Drive
    Baton Rouge, LA 70810
    Phone: 225-761-4436
12. Child Development and Learning Center
    7315 Exchange Place
    Baton Rouge, LA 70806
    Phone: 225-924-3414
14. Discovery Head Start Center
    9700 Scenic Highway
    Baton Rouge, LA 70807
    Phone: 225-775-7719
    
15. Freeman-Mathews Head Start Center
    1386 Napoleon Street
    Baton Rouge, LA 70802
    Phone: 225-387-8539
16. LaBelle Aire Head Start Center
    1919 N Cristy Drive
    Baton Rouge, LA 70815
    Phone: 225-275-0426
    Annex: 225-273-6770
18. New Horizon Head Start Center
    1111 North 28th Street
    Baton Rouge, LA 70802
    Phone: 225-344-2152
    Annex: 225-389-3014
19. Progress 1 Head Start Center
    1881 Progress Road
    Baton Rouge, LA 70807
    Phone: 225-774-8158
20. Progress 2 Head Start Center
    1881 Progress Road
    Baton Rouge, LA 70807
    Phone: 225-774-1901
    Additional Phone: 225-774-1939
22. Wonderland Head Start Center
    1500 Oleander Street
    Baton Rouge, LA 70802
    Phone: 225-346-0677
24. 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
26. 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
28. An Equal Opportunity Program
    Federal Law Prohibits Discrimination Because of Race, Color, Religion, Sex, Age, National Origin, and/or Special Needs
29. Today's Date
    Today's Date
31. Center of Choice

    1. Capital Area
    2. Discovery
    3. Charlie Thomas

    1. CDLC
    2. Freeman Matthews

    1. LaBelle Aire / Annex
    2. Progress I

    1. Progress II
    2. Wonderland
33. Referring Agency
34. Contact Person
35. Contact Person Phone Number
39. I. Expectant Mother's Information
41. Expectant Mother's Name
42. Anticipated Date of Delivery
    Anticipated Date of Delivery
44. Prenatal Physician
45. Address of Physician
47. Phone Number
49. Parent's Information
51. Parent / Guardian's Name
52. Date of Birth
    Date of Birth
53. Relationship to Child

    1. Mother
    2. Father
    3. Grandparent
    4. Other
55. Social Security Number
56. Race / Ethnicity (Optional)

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

    1. Hispanic / Latino
    2. Other
58. If other, explain.
60. Address
61. City, State
62. Zip Code
64. Home Phone Number
65. Cell Phone Number
67. Place of Employment
68. Work Phone
70. Parent's Marital Status

    1. Single
    2. Married

    1. Divorced
    2. Separated
71. Child lives with?

    1. Mother
    2. Father

    1. Legal Guardian
75. Child's Information
77. Child's Name
78. Date of Birth
    Date of Birth
79. Age
81. Social Security Number
82. Gender

    1. Male
    2. Female
83. Race / Ethnicity (Optional)

    1. African American / Black
    2. Asian
    3. Caucasian / White
    4. Hispanic / Latino
    5. Native American / Alaskan
    6. Other
85. If other, explain.
87. Language Spoken at Home:
88. Primary
89. Secondary
93. Child's Health Information
    Submit copy of Health Insurance Card
95. Health Insurance

    1. No Health Insurance
    2. LaCHIP Number
    3. MEDICAID Number
    4. Health Insurance Company
96. LaCHIP Number
97. MEDICAID Number
99. Health Insurance Company
100. Policy Number
102. Primary Care Physician
103. Address
104. Phone Number
106. Dentist
107. Address
108. Phone Number
112. Emergency Contacts
114. In case of Emergency Contact

     1. Certain Person
     2. Medical Personnel
     3. 9-1-1
     4. Share Medical Health Records
115. Name
116. Phone Number
118. In addition to Emergency Contact, child may be released to:
120. Name
121. Home Phone Number
122. Cell Phone Number
124. Name
125. Home Phone Number
126. Cell Phone Number
128. Name
129. Home Phone Number
130. Cell Phone Number
132. Name
133. Home Phone Number
134. Cell Phone Number
136. 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
138. Type
139. Type
140. Type
141. If other, explain.
145. Family Information
147. 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
149. Housing

     1. Own / Buying
     2. Renting House

     1. Apartment
     2. Homeless / Shelter

     1. Public Housing Assistance
     2. Other
151. How long at this address?
152. If other, explain.
154. Has family moved 2 or more times in the last 12 months?

     1. Yes
     2. No
156. Transportation

     1. Private Vehicle
     2. Public Transportation
     3. Friend / Relative
     4. Other
157. If other, explain.
159. Maternal Relationship
161. Relationship

     1. Mother

     1. Grandmother

     1. Legal Guardian

     1. Other
163. Name
164. Date of Birth
     Date of Birth
165. Age
167. Social Security Number
168. Race / Ethnicity

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

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
170. If other, explain.
172. Language:
173. Primary
174. Secondary
176. 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
178. Employment

     1. Full-time
     2. Part-time

     1. Disabled

     1. In-School / Training

     1. Unemployed
180. Unemployed

     1. With Previous Experience
     2. With No Previous Experience

     1. Other
181. If other, explain.
183. Work Place
184. Work Place Phone Number
186. Other Public Assistance

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

     1. Child Care Assistance
     2. Other
187. If other, explain.
189. Special Conditions / Concerns
191. Medical Conditions / Disabilities

     1. Yes
     2. No
192. If yes, describe
194. Health Insurance

     1. Yes
     2. No
195. Currently Pregnant

     1. Yes
     2. No
196. Substance Abuse

     1. Yes
     2. No
198. Physical Abuse

     1. Yes
     2. No
199. Legal Issues

     1. Yes
     2. No
203. Paternal Relationship
205. Relationship

     1. Father

     1. Grandfather

     1. Legal Guardian

     1. Other
207. Name
208. Date of Birth
     Date of Birth
209. Age
211. Social Security Number
212. Race / Ethnicity

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

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
214. If other, explain.
216. Language:
217. Primary
218. Secondary
220. 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
222. Employment

     1. Full-time
     2. Part-time

     1. Disabled

     1. In-School / Training

     1. Unemployed
224. Unemployed

     1. With Previous Experience
     2. With No Previous Experience

     1. Other
225. If other, explain.
227. Work Place
228. Work Place Phone Number
230. Other Public Assistance

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

     1. Child Care Assistance
     2. Other
231. If other, explain.
233. Special Conditions / Concerns
235. Medical Conditions / Disabilities

     1. Yes
     2. No
236. If yes, describe
238. Health Insurance

     1. Yes
     2. No
239. Currently Pregnant

     1. Yes
     2. No
240. Substance Abuse

     1. Yes
     2. No
242. Physical Abuse

     1. Yes
     2. No
243. Legal Issues

     1. Yes
     2. No
247. Other Family Relationships
249. Relationship

     1. Sibling

     1. Non-Relative
250. Relationship

     1. Sibling

     1. Non-Relative
252. Name
253. Name
255. Date of Birth
     Date of Birth
256. Age
257. Date of Birth
     Date of Birth
258. Age
260. Social Security Number
261. Social Security Number
263. Gender

     1. Male

     1. Female
264. Gender

     1. Male
     2. Female
266. Race / Ethnicity

     Optional

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

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

     Optional

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

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
269. If other, explain.
270. If other, explain.
272. Language:
273. Language:
275. Primary
276. Secondary
277. Primary
278. Secondary
280. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade
281. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade
283. Relationship

     1. Sibling

     1. Non-Relative
284. Relationship

     1. Sibling

     1. Non-Relative
286. Name
287. Name
289. Date of Birth
     Date of Birth
290. Age
291. Date of Birth
     Date of Birth
292. Age
294. Social Security Number
295. Social Security Number
297. Gender

     1. Male

     1. Female
298. Gender

     1. Male
     2. Female
300. Race / Ethnicity

     Optional

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

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

     Optional

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

     1. Hispanic / Latino
     2. Native American / Alaskan
     3. Other
303. If other, explain.
304. If other, explain.
306. Language:
307. Language:
309. Primary
310. Secondary
311. Primary
312. Secondary
314. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade
315. Education

     1. Some College
     2. High School Diploma / GED

     1. Less than 12th Grade
319. 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.
321. Federal law prohibits discrimination because of race, color, religion, sex, age, national origin, and/or special needs.
323. Parent / Guardian's Name (Print)
325. Parent / Guardian's Signature
326. Date
     Date
328. An Equal Opportunity Program
Leave This Blank:


329. Print Only

* indicates a required field