Form Center

Head Start Program Application

2. East Baton Rouge Parish 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 - 2018 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>

    3250 N Acadian Thruway E
    Baton Rouge, LA 70805
    Phone: 225-806-6023
    

11. Charlie Thomas Head Start Center
    8686 Pecan Tree Drive <br> Baton Rouge, LA 70810 <br> Phone: 225-761-4436

    8686 Pecan Tree Drive
    Baton Rouge, LA 70810
    Phone: 225-761-4436

12. Child Development and Learning Center
    7315 Exchange Place <br> Baton Rouge, LA 70806 <br> Phone: 225-924-3414

    7315 Exchange Place
    Baton Rouge, LA 70806
    Phone: 225-924-3414

14. Discovery Head Start Center
    9700 Scenic Highway <br> Baton Rouge, LA 70807 <br> Phone: 225-775-7719 <br>

    9700 Scenic Highway
    Baton Rouge, LA 70807
    Phone: 225-775-7719
    

15. Freeman-Mathews Head Start Center
    1386 Napoleon Street <br> Baton Rouge, LA 70802 <br> Phone: 225-387-8539

    1386 Napoleon Street
    Baton Rouge, LA 70802
    Phone: 225-387-8539

16. LaBelle Aire Head Start Center
    1919 N Cristy Drive <br> Baton Rouge, LA 70815<br> Phone: 225-275-0426 <br> Annex: 225-273-6770

    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 <br> Baton Rouge, LA 70802 <br> Phone: 225-344-2152 <br> Annex: 225-389-3014

    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 <br> Baton Rouge, LA 70807 <br> Phone: 225-774-8158

    1881 Progress Road
    Baton Rouge, LA 70807
    Phone: 225-774-8158

20. Progress 2 Head Start Center
    1881 Progress Road <br> Baton Rouge, LA 70807 <br> Phone: 225-774-1901 <br> Additional Phone: 225-774-1939

    1881 Progress Road
    Baton Rouge, LA 70807
    Phone: 225-774-1901
    Additional Phone: 225-774-1939

22. Wonderland Head Start Center
    1500 Oleander Street <br> Baton Rouge, LA 70802 <br> Phone: 225-346-0677

    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 <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

26. 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

28. 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

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

    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.

     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