Big Five Community Services, Inc.

BIG FIVE HEAD START
ONLINE ENROLLMENT APPLICATION

Big Five is an equal opportunity employer and service provider

Dear Parent/Guardians,

We are happy you are interested in Big Five’s Head Start Program. This page will guide you through the application process, so please read this page carefully. The online application will help us determine if your child/family will meet the requirements set by the federal Head Start program. You must complete all the information to be considered for the program.

Once you have submitted the online application, please open the remainder of the application by clicking the link “Print Application”. You will need to print this packet and complete the remainder of the application. A Big Five representative will contact you to set up an appointment to complete your application. Please have the packet completed and copies of the documents listed available on the day of your appointment.

We must have a copy of the following in order to process your application and determine eligibility:

Proof of income (Income Tax 1040 forms, W-2 forms, 3 Pay Stubs, Written statement from employers or documentation showing current status recipient of Public Assistance).
Child’s Birth Certificate
Insurance coverage can be ( Private Insurance card, Sooner Care card or CDIB card)

It is also very important that you share sometimes very personal information because certain aspects of a child’s life give the application more priority, so please be sure we know:

Child’s Disability – Diagnosed or suspected
Parental Status of family – Single or Two Parent, Foster Parent/guardianship, Grandparent
Homeless/temporary housing/living with relatives/HUD or other subsidized housing
Immediate family needs/crisis/Referral from an agency or professional
Serious child/family health problems
English as a second language
If your family receives Food Stamps, Sooner Care, SSI, WIC, or TANF
Early completion of a Physical exam, Dental exam and Blood Lead Test
Priority points are also given to families who previously enrolled in Big Five Head Start

Please Fill Out “The Head Start Online Application” Below

Please fill out the application in its entirety to the best of your ability.

Head Start Application

Applicant

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If other, what

Hispanic

English Proficiency

other Language Proficiency

Primary Language

Second Language

Primary Health Insurance

Insurance #

Other Health Insurance

Insurance #

Medicaid

Medicaid #

Check one

On Medicaid

Not Eligible

Potentially Eligible

Doctor

Dentist

Have Transportation

Yes

If no transportation, need the bus?

Yes

Transportation Type

Housing Type

Housing Payment

Other

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

CDIB

Yes

Citizenship Status

Adult 1 (Primary) Information

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

other Language Proficiency

Primary Language

Second Language

Education Level

If High School, Highest Level Completed

Employment Status

Child's Relationship

Custody

Check all that apply

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, subsidized?

email address

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Adult 2 Information

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

other Language Proficiency

Primary Language

Second Language

Education Level

If High School, Highest Level Completed

Employment Status

Child's Relationship

Custody

Check all that apply:

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, subsidized?

email address

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Transportation

Have transportation?

If yes, what type?

If no, does child need to be transported by bus?

Housing

Type of housing

Housing Payment

*If family has more than one child applying for services, please complete a separate copy of this form for each applicant.

Additional Child (Non-Applicant)*

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

Other Language

other Language Proficiency

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Additional Child (Non-Applicant)*

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

Other Language

other Language Proficiency

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Additional Child (Non-Applicant)*

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

Other Language

other Language Proficiency

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Additional Child (Non-Applicant)*

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

Other Language

other Language Proficiency

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Additional Child (Non-Applicant)*

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

Other Language

other Language Proficiency

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Additional Child (Non-Applicant)*

First Name

Middle Name

Last Name

Suffix

Nickname

Birthday

Gender

SSN # / Alt. ID

Race

If Other, What

Hispanic

English Proficiency

Other Language

other Language Proficiency

HEALTH INSURANCE

Health Ins./What Type

DISABILITY INFORMATION

Have a disability?

Yes

CSBG FAMILY INFO

Military Status

Citizenship Status

Non-Cash Benefits

If other non-cash benefits please state

Marital Status

Disconnected Youth

CDIB

Yes

Income & Contacts

Applicant Name

Birthday

Family Information

Living Address

Address Line 2

City

State

Zip

County

Mailing Address (If different)

Address Line 2

City

State

Zip

County

Phone Numbers

Type (Check one)

Note (for example, an extension or best time to call)

Phone Number

Type (Check one)

Note (for example, an extension or best time to call )

Phone Number

Type (Check one)

Note (for example, an extension or best time to call )

Parental Status

One Parent

Two Parent

Primary Language at Home

Homeless Family

Active Duty Military

Family Income

Tanf

Supplemental Security Income

WIC

SNAP/Food Stamps

Interview Date Verified (agency use only)

Verified by (agency use only)

Family Member

Income Amount $

Amount Per

Annual Amount $

Source of Income

Verification

Family Member

Income Amount $

Amount Per

Annual Amount $

Source of Income

Verification

Family Member

Income Amount $

Amount Per

Annual Amount $

Source of Income

Verification

Emergency Contacts & Individuals with Pick-Up Permission

Contact 1

Name

Relationship

Emergency Contact

Release To

Address

City

State

Zip

Phone # 1

Type

Phone # 2

Type

Phone # 3

Type

Contact 2

Name

Relationship

Emergency Contact

Release To

Address

City

State

Zip

Phone # 1

Type

Phone # 2

Type

Phone # 3

Type

Contact 3

Name

Relationship

Emergency Contact

Release To

Address

City

State

Zip

Phone # 1

Type

Phone # 2

Type

Phone # 3

Type

Certification: I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.

Parent/Guardian Signature

Date

1. Child Health History: Has the child ever had any of these conditions? (Please give explanation to any "checked" answers below)

Please explain any checked answers.

2. Is child receiving treatment for any of the following health conditions?

Condition

Anemia (low iron)

Overweight

Vision Problems

Diabetes

Asthma

Hearing Difficulties

High Lead Levels

Other

3. Is the child currently taking medication?

Yes

If yes, name of medication.

Dose:

How often?

Will Head Start staff need to administer this medication

Yes

(If "Yes" a special consent form must be completed entirely before the child can receive medication while attending the Head Start program)

4. Does this child have a diagnosed health problem?

Yes

If yes, name of physician.

Address

Phone #

5. Has this child ever had surgery?

Yes

If yes, please explain.

6. Has this child ever had a seizure?

Yes

If yes, please explain: Cause if known.

How often?

Date of last seizure.

7. Has the child ever been diagnosed with asthma?

Yes

If yes, please explain. Cause if known.

How often?

Date of last asthma attack.

8. Has the child ever had an allergic reaction?

Yes

If yes, please explain the reaction.

Cause if known.

Date of last reaction.

Explain "Yes" answers:

10. Has this child ever been involved in a child abuse &/or neglect incident or case?

Yes

If yes, please explain.

11. Does child have a regular doctor?

Yes

If yes, please explain. When did you obtain doctor for child?

Where does child receive medical care?

Doctor Office

Clinic

Date of last physical exam.

Name of Doctor

Address

Phone Number

12. Does child have a regular dentist?

Yes

If yes, please explain. When did you obtain dentist for child?

Where does child receive dental care?

Dentist Office

Clinic

Date of last dental exam.

Name of Dentist

Address

Phone Number

13. Are child's immunizations up to date? (If "No" child cannot be accepted into program.)

Yes

Disability Information:

Children with special needs may receive priority for Head Start enrollment.

1. Does your child have any additional condition that could interfere with his/her daily activities?

Yes

If yes, please explain.

2. Is this child's routine screenings (developmental, sensory, and behavioral) completed?

Yes

If yes, does the child need follow-up assessment or format evaluation to determine if the child had a disability?

3. Does your child have a disability? (If no, please go to question #8)

Yes

4. Type of special needs or disability?

5. Has the disability been professionally diagnosed?

Yes

If yes, by whom?

6. Is the child receiving special services for the disability?

Yes

If yes, type of services?

7. Does child currently have (IEP) Individual Education Plan?

Yes

8. In your opinion, does your child have a special need that has not yet been diagnosed?

Yes

NUTRITION ASSESSMENT SURVEY

Name of Child:

Center Name

Please answer the following questions regarding your child.

1. Is your child taking a vitamin supplement?

Yes

If yes, are they prescribed?

Yes

2. Does your child have any persistent/current issues?

Yes

If yes, please select:

Nausea or vomiting

Diarrhea

Constipation

Trouble Swallowing

3. Has your child experienced a dramatic weight change in the past year?

Yes

If yes, please explain:

Is your child on a special diet?

Yes

If yes, please list type of diet:

5. Does your child have an allergy to food?

Yes

If yes, please list:

6. Is your child enrolled in a Nutrition Program?

Yes

If yes, which program?

WIC

Food Stamps

Other

7. Does your child use spoon and fork?

Yes

8. Does your child have a feeding tube?

Yes

Other method?

Yes

If yes, please list.

9. Do you have any concerns about your child's size?

Yes

If yes, please check your concern:

Too Thin

Too Small

Too Heavy

Too Tall

10. Please check which meals your child eats daily.

Breakfast

Lunch

Dinner

Snack

11. On a WEEKLY basis, how often does your child eat items from the following food groups? (Please check number)

a. Dairy (milk, cheese, yogurt)

b. Meat, fish, poultry, eggs or dried beans/peas, peanut butter?

c. Grains (rice, grits, bread, cereal, tortillas)

d. Vegetables (greens, carrots, broccoli, winter squash, pumpkin, sweet potatoes)

e. Fruit or juices (orange, grapefruit, tomatoes, grapes)

f. Oil, butter, margarine, etc.

g. Sweets (cake, cookies, soda/pop, fruit drinks (Kool-Aid), candy

*Starred answers may require follow-up.

Email a copy to

optional

Required Fields

Online Enrollment Application