Fillable 2020-2021 Child Information General (Clover Park Technical College)

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2020-2021 Child Information General (Clover Park Technical College)

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Early Learning Application
2020-2021
Revised 01/22/2020
08.001.98
Page 1 of 6
Language: English
Child Information – General
First Name: Middle Initial: Last Name:
Date of Birth (month/day/year):
Gender: ☐M ☐F
What is this child’s home language? 2
nd
language:
Does this child speak:
☐Only English ☐Mostly English and another language ☐Some English, but mostly another language
☐Both English and another language the same (bilingual) ☐Only a language other than English
Is this child Hispanic/Latino? ☐Yes ☐No
What is this child’s race? Check all that apply:
☐
African/African American/Black
☐Asian
☐Alaska Native/Native American/American Indian
☐
Native Hawaiian or Pacific Islander
☐White
☐Not listed above:
What is your family’s heritage/tribe/country of origin?
Has this child previously attended these programs? Only check the most recent:
☐None
☐ Early Support for Infants and Toddlers (ESIT) or
any Birth-to-Three/Home Visiting program
☐Head Start/Early Head Start/ECEAP in King or
Pierce County, Washington State
☐Head Start/Early Head Start/ECEAP in another
Washington State County
☐Migrant/Seasonal Head Start
anywhere in Washington State
When did this child last attend?
Is this child currently enrolled in a community slot at this site? ☐Yes ☐No
Is this child a sibling of a currently enrolled child at this site? ☐Yes ☐No
The questions below are for information only. Answering “Yes” will not affect your eligibility or enrollment in the program.
Is this child in official foster care or kinship care with a grant amount?
☐
Yes
☐
No
If yes, what is the Case Number or Client ID Number?
What is the monthly grant/payment amount and source? $
# of children covered by grant amount:
☐DSHS ☐SSI ☐Tribe ☐Other
Is this child in kinship care without a grant amount? ☐Yes ☐No
Was this child adopted after foster care or kinship care? ☐Yes ☐No
Does your family currently receive services through Child Protective Services (CPS), Family Assessment Response (FAR), or Indian Child Welfare
(ICW)? ☐Yes ☐No
Has your family received services from CPS/FAR/ICW in the past? ☐Yes ☐No
Is your family currently approved for child care through CPS or FAR?
☐Yes – How many approved hours per week?
☐No
Has this child ever been asked to leave an early learning program because of behavior issues? ☐Yes ☐No
Early Learning Application 2020-2021
Revised 01/22/2020
08.001.98
Page 2 of 6
Language: English
Child Information – Health
Does this child have medical insurance?
☐
Yes
☐
No
If yes, what type?
☐
Washington Apple Health/ProviderOne
☐
Private Insurance
☐
Tribal
☐
Military Medical Coverage
Does this child have a regular doctor or medical clinic?
☐Yes - Name of clinic/provider:
Name of medical professional:
☐No
Did this child have a well-child exam within the last 12 months?
☐
Yes – Date of last exam (month/day/year):
☐
No
☐
Date Unknown
What is your child’s immunization status? ☐Fully immunized ☐Exempt ☐Not fully immunized or exempt ☐Not sure
Does this child have dental insurance?
☐
Yes
☐
No
If yes, what type?
☐
Washington Apple Health/ProviderOne
☐
Private Insurance
☐
Tribal
☐
ABCD
☐
Military Dental Coverage
Does this child have a regular dentist or dental clinic?
☐Yes - Name of clinic/provider:
Name of dental professional:
☐No
Did this child have dental exam within the last 6 months?
☐
Yes – Date of last exam (month/day/year):
☐
No
☐
Date Unknown
Has this child been diagnosed by a Health Care Provider with a chronic health condition (may include asthma, cancer, diabetes, seizures, ADHD,
autism, spina bifida, sickle cell disease, or life-threatening allergies)?
☐Yes – Please describe: The health condition is considered: ☐Severe ☐Moderate ☐Mild
☐
No
Child Information - Development
Do you have concerns about this child’s health? ☐Yes – check all that apply below ☐No
☐Low birth weight (less than 5.5 lbs/5 lbs 8 oz.)
☐
Hearing
☐Preterm birth less than 37 weeks
☐
Fine motor/gross motor
☐Drug/alcohol affected
☐
Tooth pain/decay/bleeding gums
☐Vision ☐Food intolerance/special diet –
Please describe:
Does this child have a current and active Individual Education Plan (IEP) or Individual Family Service Plan (IFSP)?
☐
Yes – Please provide a copy with your application.
☐
No – Check if any of these apply:
☐My child has a diagnosed developmental delay or disability, has no IEP, or is being referred for evaluation.
☐
My child has a suspected developmental delay or disability.
Early Learning Application 2020-2021
Revised 01/22/2020
08.001.98
Page 3 of 6
Language: English
Parent/Guardian Information
This child lives with:
☐
One parent/guardian (complete Parent/Guardian 1)
☐
Two parents/guardians in the same household (complete Parent/Guardian 1 & 2)
☐
Two parents/guardians in two households (complete Parent/Guardian 1 & 2)
Parent/Guardian 1 Parent/Guardian 2
Name
Relationship to
child
☐Biological/Adopted/Stepparent ☐Biological/Adopted/Stepparent
☐
Foster Parent
☐Grandparent
☐
Aunt/Uncle
☐Other:
☐
Foster Parent
☐Grandparent
☐
Aunt/Uncle
☐Other:
Gender
☐M ☐F ☐Not specified ☐M ☐F ☐Not specified
Date of Birth
(month/day/year)
Address
Phone
☐Home ☐Cell ☐Work
☐Home ☐Cell ☐Work
Alternate Phone
☐Home ☐Cell ☐Work
☐Home ☐Cell ☐Work
Email
Were you under
age 18 when this
child was born?
☐Yes ☐No ☐N/A ☐Yes ☐No ☐N/A
What language(s)
do you speak?
Do you need an
interpreter for this
language?
☐Yes ☐No ☐Yes ☐No
What is your race?
Check all that apply
☐African/African American/Black
☐Asian
☐Alaska Native/Native American/American Indian
☐Native Hawaiian or Pacific Islander
☐White
☐Not listed above:
☐African/African American/Black
☐Asian
☐Alaska Native/Native American/American Indian
☐Native Hawaiian or Pacific Islander
☐White
☐Not listed above:
What is the highest
level of education
you completed?
☐6
th
grade or less
☐7
th
to 12
th
grade, no diploma or GED
☐High school diploma
☐GED
☐Some college/advanced training
☐College/professional certificate
☐Associate degree
☐Bachelor’s degree
☐Master’s or doctorate degree
☐None
☐6
th
grade or less
☐7
th
to 12
th
grade, no diploma or GED
☐High school diploma
☐GED
☐Some college/advanced training
☐College/professional certificate
☐Associate degree
☐Bachelor’s degree
☐Master’s or doctorate degree
☐None
Early Learning Application 2020-2021
Revised 01/22/2020
08.001.98
Page 4 of 6
Language: English
Parent/Guardian 1 Parent/Guardian 2
Are you currently
employed?
☐Yes – How many hours per week (including travel)?
Employer name & phone #:
☐No
☐No, retired or disabled
☐Seasonal
☐Yes – How many hours per week (including travel)?
Employer name & phone #:
☐No
☐No, retired or disabled
☐Seasonal
Are you currently in
job training or
school?
☐Yes – How many hours per week (including class
time, study time, travel)?
School name & major/goal:
☐No
☐Yes – How many hours per week (including class
time, study time, travel)?
School name & major/goal:
☐No
Are you in an
approved WorkFirst
activity?
☐Yes – Describe the activity and the number of approved
hours per week:
☐No
☐Yes – Describe the activity and the number of approved
hours per week:
☐No
Are you or have
been in the U.S.
military?
☐Yes, current service member
☐Yes, currently deployed or have been in the last 12
months/for a total of 19 months
☐Yes, veteran
☐No
☐Yes, current service member
☐Yes, currently deployed or have been in the last 12
months/for a total of 19 months
☐Yes, veteran
☐No
Family Concerns
Please check areas of concern that you have for yourself/family in your household:
☐Child’s parent/guardian has a disability or is
chronically ill and is:
☐Unable to engage in
work/school/family life
☐Somewhat able to engage in
work/school/ family life
☐Mostly able to engage in
work/school/family life
☐Child’s parent/guardian has learning
difficulties, no disability
☐Household mental illness, including
maternal depression (child is diagnosed, or
adult is experiencing)
☐Household domestic violence (past or
current)
☐Household drug/alcohol issues or substance
abuse (past or current)
☐Family is socially isolated, with complete or
near-complete lack of contact with others
☐Getting or keeping a job
☐Legal concerns
☐Child’s parent/guardian is a migrant worker
☐Recent immigrant/refugee (past 5 years)
☐Child’s parent/guardian is incarcerated
☐Loss of a parent (death, abandonment, or
deportation)
☐Child’s parents/guardians divorced or
separated during child’s life
☐Previously homeless (in the last 12 months)
☐Concerns with housing
Family Living Situation
Does this household receive subsidized housing such as a housing voucher or cash assistance for housing? ☐Yes ☐No
What is your family’s current housing situation? The McKinney-Vento Act provides services and supports for children and youth experiencing
homelessness. Your answers may help us determine the services your child may be eligible to receive.
☐
Rent
☐Own
☐
In a motel
☐ In a shelter
☐
A car, park, campsite, or similar location
☐ Transitional Housing
☐
Moving from place to place/couch surfing
☐ In a residence with inadequate facilities (no water, heat, electricity)
☐
In someone else’s house or apartment with another family:
☐ By choice (e.g. to save money, to be close to family, etc.)
☐
Due to loss of housing, economic hardship, or similar reason
☐
Other – Please describe:
Early Learning Application 2020-2021
Revised 01/22/2020
08.001.98
Page 5 of 6
Language: English
Family Income and Family Size
Check all that apply if you, this child, or another person living in your home related to you by blood, marriage, or adoption receive these types of
Public Assistance:
☐SSI for disability received by: ☐Child ☐Parent/Guardian ☐Other – Relationship to child:
☐Temporary Assistance for Needy Families (TANF) cash.
Check if you also have the following: ☐Child-only TANF ☐WorkFirst ☐Working Connections Child Care subsidy
Please list additional people living in this child’s primary household below, not including yourself or this child.
Name (First and Last)
Birthdate
(month/day/year)
Relationship to
child
Do you financially support
this person?
Is this person related to you by
blood, marriage, or adoption?
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
☐Yes ☐No ☐Yes ☐No
What is the total number of family members living in your home, including yourself and this child?
What is your total estimated household income for the last calendar year or the last 12 months?
I promise that the information on this form is true and correct. I have reported all my income and family size, as required by the Early Learning
Programs. If I knowingly provide false information, I understand my family may be unable to continue program services. Additionally, if my child is
enrolled in ECEAP, I may have to repay the amount spent on my child.
I understand that information from this application is entered in various Early Learning databases operated by the Department of Children, Youth, and
Families (DCYF) and Puget Sound Educational Service District (PSESD). DCYF and PSESD are committed to protecting confidential and personal
information that could identify a child or family. No information related to immigration status is entered in the databases or shared with state or
federal agencies. Information in the databases may be used for the following:
• Research studies to determine if participating in Early Learning helps children later in life.
• To prove Washington State spends some of their own dollars on programs for families, which is required to receive Temporary Assistance for
Needy Families dollars from the federal government.
Parent/Guardian Signature _______________________________________________________ Date _________________
(ECEAP Staff: Enter this date in ELMS)
*Staff Only – If not signed, complete below. Parent signature must be obtained as soon as possible, or no later than the enrollment visit.
Reviewed and received verbal verification on (date):
Staff Initials:
(ECEAP Staff: Enter this date in ELMS if not signed – you cannot update this once the ELMS application is locked)
Staff Only
Please sign in person if filling out Online
click to sign
signature
click to edit
Early Learning Application 2020-2021
Revised 01/22/2020
08.001.98
Page 6 of 6
Language: English
Child’s Age: Total Verified Family Size: Total Verified Income: Total Points:
Site Name/ID:
Date received:
(This date will determine eligibility timeframe)
Date staff reviewed application with family: Date sent to PSESD (N/A for ECEAP only sites):
EHS Only - Is this child a newborn taking the mother’s slot?
☐
Yes
☐
No
If yes, mother’s name:
For Homeless Families – Check the services that are needed or desired by the family and provide resources as soon as possible:
☐Child care resources
☐Clothing resources
☐School supplies
☐Medical/dental referral
☐Housing/shelter referral
☐Immunization/medical records
☐Vision referral
☐Hygiene products/toiletries
☐Food resources
☐Birth certificate
☐Medicaid/DSHS services – Food stamps/TANF
☐College/vocational/technical resources
☐School transportation (if site provides)
☐Other:
Staff Name & Signature: Date:
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2020-2021 Child Information General (Clover Park Technical College)

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Completed 4 February 2021

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