Online Enrollment Application

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

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Adult 1 (Primary) Information

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Adult 2 Information

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Transportation




Housing



*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)*

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Additional Child (Non-Applicant)*

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Additional Child (Non-Applicant)*

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Additional Child (Non-Applicant)*

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Additional Child (Non-Applicant)*

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Additional Child (Non-Applicant)*

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Income & Contacts

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Family Information

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Family Income





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Emergency Contacts & Individuals with Pick-Up Permission
Contact 1

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Contact 2

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Contact 3

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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.

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


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


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


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NUTRITION ASSESSMENT SURVEY 2017-2018

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Please answer the following questions regarding your child.






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







*Starred answers may require follow-up.


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Required Fields