Fillable MA HEAD START APPLICATION CHOCTAW NATION OF OKLAHO (Choctaw Nation)

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MA HEAD START APPLICATION CHOCTAW NATION OF OKLAHO (Choctaw Nation)

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CHOCTAW NATION OF OKLAHO
MA HEAD START APPLICATION
Dear Parent/Guardian,
Head Start is a comprehensive early childhood development program that promotes school readiness
and is directed primarily toward economically disadvantaged families having children ages three to five
years old. All races and ethnicities are served.
Please note, an interview with a staff member is a part of the application process.
DOCUMENTS NEEDED (Copies only; Originals will not be returned)
♦ Income Verification – The documents need to show income for the past 12 months. All parent or
guardian income needs to be submitted. This includes, but is not limited to:
Pay Stubs for the past 12 Months, or Latest Income Tax Return (1040) or W-2
Child Support
Supplemental Security Income (SSI)
Social Security and/or Disability Income
Completed “Employer Income Verification” (Showing hours worked and pay rate - only if
you do not have pay stubs)
♦ Birth Certificate (or other proof of age)
♦ Immunization Record (required if selected for enrollment)
♦ CDIB (if applicable or parent’s CDIB with child's birth certificate listing the tribal member as a parent)
♦ Current IEP (Individualized Education Plan) or IFSP (Individualized Family Service Plan) (if
applicable)
♦ Legal Documents/ Court Orders for Foster Child (if applicable)
♦ TANF Document (if applicable)
SCHEDULE YOUR INTERVIEW
Return documents and completed application to your local center or mail to the address listed below. A
center staff member will call to schedule a date and time for an interview.
Return applications and required documents to your local center or email to:
headstartrecruitment@choctawnation.com
Applications can also be mailed to:
Choctaw Nation Head Start
Attn: ERSEA/Ashley Adams
P.O. Box 1210, Durant, OK 74702-1210
If you have any questions please call your local center or call 1-800-522-6170, ext. 2219
PLEASE NOTE:
Completing this application does not guarantee enrollment. Selection is determined on a priority
based point system, not on a first come first serve basis.
Is this adult legally married to the Primary Parent/Guardian or a Biological Parent of Applying Child?
 Yes  No (if no, please go to page 2)
Highest Grade Completed Employment Status Child’s Relationship
Highest Grade Completed Employment Status Child’s Relationship
Application for Child Enrollment
Choctaw Nation Head Start
P.O. Box 1210 • Durant, OK 74701
(580) 924-8280 • (800) 522-6170, ext. 2219
Applicant & Family Member Information
Applicant
First Middle Last Sufx Nickname Birthdate Gender
HispanicRace IfAmericanIndian/AlaskaNative,whattribe?
EnglishProciency
Asian
Black
White
Other:
Physical Therapy
Occupational Therapy
Speech Therapy
Medicaid / Soonercare
Indian Health Services
Private Ins. ____________________
Indian Health Services
Private Ins. ______________
OTHER_________________
None
Little
Moderate
Procient
Yes
No
American Indian/ Alaska Native
Hawaiian/Pacic Islander
Multi-Racial
Preferred Head Start Center
________________________
Male
Female
DoeschildhaveaCDIB? DoesparenthaveaCDIB?
Yes
No
Yes
No
Yes
No
PrimaryHealthCoverage SecondaryHealthCoverage
Male
Female
Male
Female
Yes
No
Yes
No
Primary Parent/Guardian
First Middle Last Sufx BirthdateGenderHispanic
First Middle Last Sufx BirthdateGenderHispanic
Race Custody
Checkallthatapply EnglishProciency
OtherLanguage(spoken)
Race Custody
Checkallthatapply EnglishProciency
OtherLanguage(spoken)
Asian
Black
White
Other:
Asian
Black
White
Other:
None
Little
Moderate
Procient
None
Little
Moderate
Procient
Associate’s
Bachelor’s
Master’s
Col Deg/Train
HS Graduate
Associate’s
Bachelor’s
Master’s
Col Deg/Train
HS Graduate
Full Time
Part Time
Seasonal
Unemployed
Full Time
Part Time
Seasonal
Unemployed
Full Time & Training
Part Time & Training
Training or School
Retired or Disabled
Full Time & Training
Part Time & Training
Training or School
Retired or Disabled
Biological Adopted Step
Grandchild
Foster
Other Relative - Relation:_____________
Other_____________
Biological Adopted Step
Grandchild
Foster
Other Relative - Relation:_____________
Other_____________
Lives with Family
Provides Financial Support
Teen Parent
Lives with Family
Provides Financial Support
Teen Parent
GED
Grade 11 or
below
Grade 11 or
below
GED
Yes
No
Yes
No
American Indian/ Alaska Native
Hawaiian/Pacic Islander
Multi-Racial
American Indian/ Alaska Native
Hawaiian/Pacic Islander
Multi-Racial
Email Address:
Email Address:
 
 
Adult 2/Guardian Living in the home with the applying child.
 Yes   No
 Yes
   No
If yes, which school?__________
 Yes (specify)
  
 No
 Yes (specify)
  
 No
Doeschildhaveadisability?
DoeschildhaveanIEP
throughpublicschool?
DoeschildhaveanIFSPthroughSoonerStart?
Doeschildhaveahealthconditionthatwillrequire
accommodationsoradaptionstotheschoolenvironment?
HasthischildeverattendedEarlyHeadStartorHeadStart?
If yes, include location of center
If using parent’s, a birth certicate is requiredIf Yes, parent’s CDIB not required.
Please specify:
Please specify:
* If a family has more than one child applying for Head Start, please complete a separate application for each child.
Additional Children, -Not Listed on Page 1- Living in home with applying child and supported by or supporting Parent/Guardian.
Additional Adults, -Not Listed Above- Living in home with applying child and supported by or supporting Parent/Guardian.
Name (First, Middle, Last) Race Birthdate (required) Gender Relation Previously attended Choctaw Head Start?
Name (First, Middle, Last) Race Birthdate (required) Gender Relation
# of Adults in Household # of Children in Household Total (NOTE:Totalmustmatchthoselistedas
householdmembers.)
 Yes   No
 Yes
   No
 Yes
   No
 Yes
   No
 Yes
   No
 Yes
   No
 Yes
   No
 Yes
   No
 Cell   Home   Work   Other  Mom   Dad   Other
 Mom
   Dad   Other
 One
   Two
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Cell
   Home   Work   Other
Family Information
LivingAddress AddressLine2 Zip City State
MailingAddress(ifdifferent) AddressLine2 Zip City State
PhoneNumbers Type(check one)
*Legal denition of Homeless attached. – Please read rst.
Parental Status
(check one)
Homeless
Family*
ActiveDuty
Military
ReferredbyChild
Welfare Agency
Receiving
SNAP/FoodStamps
Receiving
WIC
Primary Language
at Home
Family Information, Income & Contacts
 Yes   No  Yes   No
Family Assistance (Please list all income received)
TANF SupplementalSecurityIncome
Dual Custody? (50/50)  Yes If yes, please give a brief description of arrangements:   No
 Yes (If yes, please attach court document showing monthly amount or 12 month DHS Print-out)
 No
DoyoureceiveChildSupport?
 Paid Weekly
 Paid Bi-Weekly
 Paid Bi-Monthly
 Paid Monthly
 Paid Annually
 Other:
 Paid Weekly
 Paid Bi-Weekly
 Paid Bi-Monthly
 Paid Monthly
 Paid Annually
 Other:
 Paid Weekly
 Paid Bi-Weekly
 Paid Bi-Monthly
 Paid Monthly
 Paid Annually
 Other:
*NOTE: Dual Custody of 50/50 requires income documents and household members list with birthdates for both families.
Attach information to application.
Family
Member
ADULT 1:
ADULT 2:
Adult 1/Guardian
Income/Benet
Do you currently have active
employment with Choctaw Nation?
Adult 2/Guardian
Income/Benet
Other Adult Guardian
Income/Benet
Employer
Parent/Guardian Signature
REV 12/17 JJ
Choctaw Print Services • 580-924-1120
Date
(Listnoamounts-IncomeDocumentsRequired.)
By signing this document, I certify that the above 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 condence
within the agency and is accessible to me during normal business hours.
ConsentforThird-PartyVerication
 Iconsenttoallowthereleaseofallinformationtoanythird-partyforvericationandreportingpurposes.
 I do notconsenttoallowthereleaseofallinformationtoanythird-partyforvericationandreportingpurposes.
 Yes   No
 Yes   No
 Yes
   No
 Yes
   No
 Yes   No
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MA HEAD START APPLICATION CHOCTAW NATION OF OKLAHO (Choctaw Nation)

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Completed 13 March 2021

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