Fillable www.myheadstart.org D ear Parent/Guardian, T hank you for

Fill Online, Printable, Fillable, Blank www.myheadstart.org D ear Parent/Guardian, T hank you for Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

www.myheadstart.org D ear Parent/Guardian, T hank you for

On average this form takes 50 minutes to complete

The www.myheadstart.org D ear Parent/Guardian, T hank you for form is 3 pages long and contains:

  • 2 signatures
  • 143 check-boxes
  • 124 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
D
ear Parent/Guardian,
T
hank you for your interest in the Head Start and State Preschool Programs. We provide full-day and part-day
preschool services, free of charge or low cost, to eligible families who live in Santa Clara and San Benito
Counties. We also offer home-based and center-based services for newborn children to 36 months. Please fill
out the application completely and if you need help, you can call us at (408) 453-6900 or (800) 820-8182,
Monday through Friday from 8:00 am to 5:00 pm.
P
lease note that as part of the enrollment process, you will have an interview with a staff member.
DOCUMENTS YOU WILL NEED (Copies only; Originals will not be returned)
Income Verification – The documents need to show your income for the past 12 months. All parent
or guardian income needs to be submitted. This includes, but not limited to:
Pay Stubs for the past 12 Months, or recent 2 months of pay stubs in combination with
o Latest Income Tax Return (1040) or W-2
Notice of Action (if receiving CalWORKs)
Child Support
Supplemental Security Income (SSI)
Disability Income
Completed “Employer Income Verification” (This is a form showing hours worked and pay
rate - only if you do not have pay stubs)
Birth Certificate(s) (for enrolling child and all siblings under 18)
Immunization Record
Proof of Address (Example: phone bill, water bill, etc.)
Current IEP (Individualized Education Plan) or IFSP (Individualized Family Service Plan) (if applicable)
Legal Documents/ Court Orders for Foster Child (If Applicable)
Full Time Employment or School/Training Verification (if you would like full day services)
SCHEDULE YOUR INTERVIEW
When you have gathered your documents and completed the application, call our office and an Early Learning
Services Staff will help you schedule a date and time for an interview at a location near you. Please be sure to
bring all the documents listed above and the completed application.
Please call 1 (408) 453-6900 or 1 (800) 820-8182 to schedule your appointment.
P
LEASE NOTE:
If your child is accepted into the program, you will be required to present current TB Risk Assessment and
Physical Exam within 30 days of enrollment. They may be submitted with the application if you have them.
SANTA CLARA COUNTY OFFICE OF EDUCATION
Early Learning Services Department
1290 Ridder Park Drive, MC 225
San Jose, CA 95131-2304
www.myheadstart.org
Page 1 of 2
CPID _________
ELS PRESCHOOL SERVICES APPLICATION
I would like to apply for
AM Session PM Session Full Day* Single Session
EHS Full Day* 0-3 years old) EHS Family Child Care (0-3 years old ) EHS Home Visiting (0-3 years old)
*Note: Full day requires that both parents/guardians must be working full time more than 30 hours per week or in school full time taking 12+ units
Child (Applicant)
First Name
Last Name
Middle
Gender
Male Female
Living Address
City/ Zip
Mailing Address (if different)
City/ Zip
Is the child in
foster care?
Yes No
Ethnicity
Hispanic/Latino
Non-Hispanic /Non-Latino
Race
Asian
White (European, Middle Eastern, North African)
Black/African American
Pacific Islander/Hawaiian
American Indian/Alaskan
More than one race (Bi-racial/Multi-racial)
Other _______________________________
Family Information
Primary language spoken at home
English
Spanish
Vietnamese
Other _________________________
What language does your child use the most?
English Spanish Vietnamese Other
_________________________
Does the child (applicant) have a sibling with a current IEP or IFSP?
Yes No
Parents/Guardians in the Home
One Parent Two Parents
What language would you like to receive written information?
English Spanish Vietnamese
Primary Parent/Guardian’s Name
Birth Date
Relationship to Child
Lives with
the Child
Yes No
Marital Status
Married Single
Divorced
Separated
Widowed
Cell Phone Number
Opt in to received Text Message
Yes No
( )
Employment Status
Employed Seasonally Employed Retired
Unemployed Seeking Employment Student
Disabled Incapacitated From _______ to _______
Primary Parent/Guardian’s Email Address
Alternate Phone Number
Cell Home Work Other
( )
Education
Less than High School Some College or AA/AS
High School Grad or GED
Bachelor’s or Advanced Degree
Secondary Parent/Guardian’s Name
Birth Date
Relationship to Child
Lives with the Child
Yes No
Marital Status
Married Single
Divorced
Separated
Widowed
Cell Phone Number
Opt in to received Text Message
Yes No
( )
Employment Status
Employed Seasonally Employed Retired
Unemployed Seeking Employment Student
Disabled Incapacitated From _______ to _______
Secondary Parent/Guardian’s Email Address
Alternate Phone Number
Cell Home Work Other
( )
Education
Less than High School
Some College or AA/AS
High School Grad or GED
Bachelor’s or Advanced Degree
List all other family members living in the household for whom you are responsible for the care and welfare - NOT LISTED ABOVE:
First Name Last Name Date of Birth
Is this person related to
the child’s parent(s)?
Is this person supported
by the parent’(s) income?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Total number in your family (Including you ) for whom you provide financial support Total number of people living in the house
Emergency Contact Information
Name
Phone
Relationship
( )
REV 5-2020
Page 2 of 2
ELS PRESCHOOL SERVICES APPLICATION
Child’s Name _________________________________ Birth Date ___________________
Family Living Situation (Check all that apply)
Shelter
Motel/Hotel
Transitional Housing
Single Room Occupancy (SRO)
Car, Trailer, or Campsite
Rented Garage
Rented Trailer, Motor Home on Private Property
Doubling/Tripling Occupancy due to economic hardship
With another adult (Not the parent/legal guardian)
Another Family’s House/Apartment
None of the options apply
Other (Not designed for human beings)
Primary Parent/Guardian
Secondary Parent/Guardian
Primary Parent/Guardian’s Name
Has Income
Y
N
Secondary Parent/Guardian’s Name
Has Income
Y
N
Check all that apply. Do you receive:
TANF/CalWORKs (no food stamps)
SSI
Child Support
Other sources of income__________________________
Check all that apply. Do you receive:
TANF/CalWORKs (no food stamps)
SSI
Child Support
Other sources of income__________________________
Employment Information
Employment Information
Employer Name
Employer Phone
( )
Employer Name
Employer Phone
( )
Employer Name
Employer Phone
( )
Employer Name
Employer Phone
( )
Pay Periods
Weekly
Every 2 Weeks
Twice Per Month
Monthly
G
ross Income $___________________________ Per___________________
Pay Periods
Weekly
Every 2 Weeks
Twice Per Month
Monthly
G
ross Income $___________________________ Per___________________
School/Training Information
School/Training Information
Are you in School or Training?
Yes
No
Units:
Are you in School or Training?
Yes
No
Units:
School Name
School Phone
( )
School Name
School Phone
( )
Technology Needs
Do you have reliable internet? □ Yes □ No □ Unsure
Do you have computer device (Laptop, Computer, IPad, Tablet)? □ Yes □ No □ Unsure
Do you have a smart phone? □ Yes □ No □ Unsure
How comfortable are you with technology and web base? □ Comfortable □ Little Comfortable □ Not comfortable
I certify that the information in this application is true and complete to the best of my knowledge. I understand that failure to report correct information
may be grounds for rejection of this application or termination of childcare services.
P
arent/Guardian’s Signature _____________________________________ Date ____________________
Early Learning Services Staff’s Signature ____________________________ Date ____________________
At intake, please have parent sign below (Required for Annual Review)
Parent/Guardian’s Signature __________________________________________________
Date ___________________
REVIEW ANNUALLY WITH PARENTS/GUARDIANS
Medications
Has your child been diagnosed with a chronic
health condition Yes No
Does your child take prescribed medications
Yes No
Will your child need to have prescribed medication at
school?
Yes No
List all medicines, prescriptive that your child takes regularly and what kind, if any, side effects the child experiences
Your child will not be given medication at school without a physician’s note and a Classroom Health Plan written with the parent and program staff.
Does your child have any known food allergies or food restrictions Yes No If yes please note___________________________________
Special Devices
Does your child use any special device(s):
Yes
No
Does your child use any special device(s) at home:
Yes
No
If yes, what kind:
If yes, what kind:
Disabilities
Does your child have an Individualized Education Plan (IEP) with your local school district of residence or County Office of
Education program? If yes, please attach copy of the most recent IEP.
Yes No
Does your child have an Individual Family Service Plan (IFSP) with an early intervention program, regional center, County
Office of Education, or school district? If yes, please attach a copy of the most recent IFSP.
Yes No
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

www.myheadstart.org D ear ParentGuardian, T hank you for

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 6 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document