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 Family Structure 2 Parent Household 1 Parent Household 2 Grandparent Household 1 Grandparent Household Number of people in the family: Do any of the following apply to your family (optional) Parent(s)/Guardian(s) work in agriculture Family member has a disability Parent/Guardian is or was in recovery Parent/Guardian is or was incarcerated Is or has experienced domestic violence Parent/Guardian is or was in foster care Parent/Guardian currently attends school Parent/Guardian does not have a high school diploma or GED Please mark the option that best describes your housing: Homeowner Renting Doubled up or 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 signing up for Early Head Start for expecting parents? Yes No Is your family receiving WIC? Yes No Primary Language English Other Is your family acquiring or learning another language in addition to English? Yes No Please list primary language: Does parent speak English? Yes No Does child speak English? Yes No Is child in daycare? Yes No Address of Childcare: City: State: Zip Code: Days in childcare: Monday Tuesday Wednesday Thursday Friday Please list all children in your family ages birth to 5. 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 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 Do you or someone in your family receive any of the following? TANF SNAP Supplemental Security Income (SSI) Social Security Income Social Security Disability Income VA Compensation Not receiving benefits Do you give Head Start of Yamhill County permission to obtain TANF & SNAP information from the Department of Human Services? Yes No Do you give permission for Head Start of Yamhill County to share your name and contact information with your local school district, Yamhill County Public Health, A Family Place Relief Nursery, Preschool Promise, Migrant and Tribal Early Head Start & Head Start programs to refer your family to parenting, child health, and preschool services? Yes No INCLUDE PROOF OF INCOME FROM ALL SOURCES, such as your previous year's IRS Form 1040, W-2(s), or your most recent pay stub. Also include documentation of unearned income, including TANF, SSI, child support, Social Security, VA benefits, unemployment benefits, retirement, tribal payments, etc. If applicable, include proof of current SNAP benefits. (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. I certify that the information above is true and complete and that misrepresentation may be considered fraud. I understand that acceptance is not guaranteed due to limited space. Start drawing Clear Done Start over Date Signed: Send
