Ready to Sign up? Leave this field blank Did an agency refer you to Head Start Yes No Agency Name & Person who referred: If an agency didn't refer you, how did you hear about Head Start of Yamhill County? A friend or family member Website Facebook Instagram Flyer Other If you answered "Other", please share how you heard about us. Is someone helping you complete this form? Yes No Primary Parent/Guardian First Name: Primary Parent/Guardian Last Name: Primary Parent/ Guardian Date of Birth: Living in the home? Yes No Secondary Parent/Guardian First Name: (optional) Secondary Parent/Guardian Last Name: (optional) Secondary Parent/ Guardian Date of Birth: (optional) Living in the home? (optional) Yes No Living Address City State Zip Code Is Mailing Address the Same as Living Address? Yes No Mailing Address City State Zip Code Cell Phone (optional) Secondary Phone (optional) Message Phone (optional) Email Address (To receive submission confirmation) Family Structure 2 Parent Household 1 Parent Household 2 Grandparent Household 1 Grandparent Household Eligibility Information (Check all that apply) (optional) Parent is or was in foster care Parent(s)/Guardian(s) work in agriculture Parent/Guardian is or was in recovery Parent/Guardian is or was incarcerated Parent/Guardian is/has experienced domestic violence Member of the child's family is medically fragile Parent/Guardian is currently attending school Parent/Guardian does not have a high school diploma or GED Number of people in the family: Housing information: Own Home Renting Living with others, friends, or family In a shelter, transitional housing, or without a home Is parent or guardian expecting a child? Yes No Due date: Are you interested in Early Head Start? Yes No Does anyone in your household receive WIC? Yes No Primary Language English Other Please list primary language: Does parent speak English? Yes No Does child speak English? Yes No Is child in daycare? (School bus transportation is limited to certain centers and classes.) Yes No Address of Childcare: City: State: Zip Code: Days in childcare: Monday Tuesday Wednesday Thursday Is child in diapers or pull-ups during the daytime? (Potty trained is not required, but preferred for pre-K.) Yes No Applicant Child Information: Date of Birth Sex of Child Male Female Does the child have a diagnosed disability? Yes No Is the child on an IFSP? Yes No Is the child a foster child or in DHS custody? Yes (please submit placement letter in lieu of proof of income) No Please list all children in your family ages birth to 5. Would you like to add a second child ages 0-5 years? Yes No Child Information: Date of Birth Sex of Child Male Female Does the child have a diagnosed disability? Yes No Is the child on an IFSP? Yes No Is the child a foster child or in DHS custody? Yes (please submit placement letter in lieu of proof of income) No Add a third child age 0-5 years? Yes No Child Information Date of Birth Sex of Child Male Female Does the child have a diagnosed disability? Yes No Is the child on an IFSP? Yes No Is the child a foster child or in DHS custody? Yes (please submit placement letter in lieu of proof of income) No Please indicate with of the following DHS benefits you are receiving: TANF SNAP SSI Social Security VA Compensation Not receiving benefits If you are obtaining TANF, SNAP, or SSI benefits, your signature below authorizes us to contact the Department of Human Services to obtain those records. (optional) Start drawing Clear Done Start over Date of Signature (optional) I give my permission for HSYC to share my name and contact information with the school district, Yamhill County Public Health, A Family Place Relief Nursery, and/or Migrant/Tribal EHS and HS Programs for referrals to their parenting and child health/ preschool programs. Yes No The above information is true and complete, and I understand misrepresentation is considered fraud. Start drawing Clear Done Start over Date Signed: Attach proof of income such as form 1040 from previous tax year, W-2 forms from previous tax year, or copy of most recent pay stub. For families with foster children, please submit their placement letter. (If you have any of these documents available now, please submit otherwise we will contact you to provide them to us.) (optional) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Proof of Income (2) (optional) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Send
