Enrollment Application – English MCCC Interactive Enrollment Application - English If you are human, leave this field blank. These Enrollment Applications are provided as interactive forms. Fill out the form and click "Confirm Signature". Your Enrollment Application file will be sent directly to the Mid-Columbia Children's Council personnel. You will be called to confirm your application. NOTE: Parent/Guardian must meet with MCCC’s staff for an interview, provide proof of family’s income, proof of applicant’s date of birth, and proof of family size BEFORE this application can be processed. NOTA: El padre o tutor debe reunirse con el personal de MCCC para una entrevista, presentar prueba de los ingresos de la familia, prueba de la fecha nacimiento del aplicante, y la una prueba de tamaño de la familia; PARA que esta aplicación pueda procesarse. Type of Program Desired? * Duration 6 hrs. per day: 6 weeks to 5 years old Preschool: 3 to 5 years old Home-Based: Prenatal to 5 years old Please fill out the following section completely to facilitate selection decisions and our ability to contact you. Please notify us if your contact information changes after you send in your application. Child/Applicant Name: Please provide First, Middle Initial and Last. Birth date: Age: Gender Male Female Due Date (If Applicant is pregnant): Living Address Street: City: State: Zip: Mailing Address Street: City: State: Zip: Email Address: Correspondence by: Postal mail E-mail Telephone Home: Cell: Message: Name at message #: Applicant's Ethnic Background: American Indian or Alaskan Native Hispanic or Latino Origin Multi-racial Asian White Black or African American Native Hawaiian or Other Pacific Island Other - If other, please indicate:Other - If other, please indicate: What language does the applicant speak at home? 1st .... 2nd Do the parents speak English? Yes No Would you like your correspondence to be in English Spanish OtherOther Does the applicant have a documented disability? Yes - If yes, what type?Yes - If yes, what type? No Does the applicant have an IFSP/IEP? Yes - If yes, where is applicant receiving services?Yes - If yes, where is applicant receiving services? No (Please provide written documentation from the professional serving your child.) Does the applicant have: Seizures Diabetes Asthma Food Allergy Other - If other, please indicate:Other - If other, please indicate: Applicants Family / Please list Parents/Guardians Name: Relationship: Birth Date: Language: Phone Number: Address: (if different than child's) Name: Relationship: Birth Date: Language: Phone Number: Address: (if different than child's) Check one: Single Parent Family Two Parent Family Foster Family Grandparents Other RelativeOther Relative Is your family a blended family? Yes No Please list all other people living in your household supported by your income. Name: Relationship to child Date of Birth Name: Relationship to child Date of Birth Name: Relationship to child Date of Birth Name: Relationship to child Date of Birth Name: Relationship to child Date of Birth Name: Relationship to child Date of Birth Please answer the following questions as completely as possible. It will help us determine the urgency of your family’s needs. (Immediate family member is anyone related to the applicant by blood, marriage, or adoption). Is a parent/guardian unemployed? Yes No Since when? Mark if stayed home parent/guardian Mark if stayed home parent/guardian Has the primary householder been unemployed for more than 6 months? Yes No Reason? Is a parent/guardian currently attending school? Yes - If yes, What is he/she studying? Yes - If yes, What is he/she studying? No Is a sibling currently enrolled in our program? Yes - If yes, Name:Yes - If yes, Name: No Has this child been enrolled in: Head Start Early Head Start When & Where? Has an immediate family member been a victim of domestic violence? Yes No Does a Parent/Guardian have a criminal history that is a barrier to accessing services such as Jobs, Food, Housing, etc.? Yes No Is an immediate family member currently incarcerated? Yes - If yes, what’s the relationship with the applicant:Yes - If yes, what’s the relationship with the applicant: No Do you have permanent housing? Yes No - If No, please describe your current housing situation:No - If No, please describe your current housing situation: Are you and your family sharing house due to hardship or are you spending more than 30% of their gross income on housing? Yes No Is an immediate family member receiving drug or alcohol treatment? Yes - If yes, who?Yes - If yes, who? No Is an immediate family member receiving mental health services? Yes - If yes, who?Yes - If yes, who? No Has anyone in your family passed away in the last 6 months? Yes - If yes, what’s the relationship to applicant?Yes - If yes, what’s the relationship to applicant? No Parent/Guardian has a major disability or health problem Yes No A family member in household (other than parent) has a major health issues/disabilities Yes No Is an immediate family member in your household receiving SSI? Yes - If yes, who? (please provide documentation)Yes - If yes, who? (please provide documentation) No Is a parent/guardian currently or formerly in the military? Yes No Is your family being served by another agency? Yes - If yes, please select the agency No Child Protective Services Employment training People for people Work source MC Center for living The Next Door Inc. CAP OtherOther Is your family receiving food stamps? (SNAP) Yes No Is your child on WIC? Yes No Do parents have adequate transportation to meet family needs? Yes No - If not, explain why not:No - If not, explain why not: (Attending medical appointments, buy groceries, take children to school, etc.) What is the mother’s highest level of education? 6 Grade or less Grade 12 or less, no diploma GED or High school Diploma Some College AA degree BA degree Masters degree What is the father’s highest level of education? 6 Grade or less Grade 12 or less, no diploma GED or High school Diploma Some College AA degree BA degree Masters degree Does the applicant live isolated from the community or is there a lack of resources available where you live? Yes - Please explain:Yes - Please explain: No Along with this application, please provide proof of income for all parents/guardians related to the child by blood, marriage, or adoption and are living in the same household. Provide the documentation needed for income age and family size at time of interview. Proof of income (all that apply) Unemployment 1040 Tax Return W-2 Child Support TANF Letter Foster Care Placement Court documentation Childcare Subsidy (SSI) Supplemental Security Income Pell Grants or scholarship letters Pay stubs Pay envelops Written statement from employers OtherOther Age (only one) Birth Certificate Immunization records Court documents IEP or IFSP WIC – Health Records TANF award letter Foster care authorization letter Adoption papers Child Profile School records Passport or visa Medical record of birth/hospital record Government document with birth date OtherOther Family Size (only one) 1040 Tax Return FASFA SNAP – TANF Letters HUD documentation Rental agreements Court or legal document Benefits letter (TANF, SSI, etc.) Foster care grant (for child-only app) OtherOther Application is incomplete without the required interview and documentation. Please make sure to bring your proof of income, age and family size at time of interview as soon as possible. Please tell us how did you hear about our program (Mark all the ones that apply) : MCCC’s employee Radio announcement Flyer Banners Referred by another agency Friend Current or Former Head Start parent Newspaper OtherOther The Head Start program includes many family support services. Parents will be asked to work with the program by: Helping in classroom activities, participating in regular Home Visits, participating in Parent Committees and by obtaining regular health and dental care for their child. In accordance with Federal law and U.S. Department of Agriculture policy this institution is prohibited from discrimination on the basis of race, color, national origin, sex, age, or disability. The Mid-Columbia Children's Council requires that you certify your application by submitting an electronic signature. By typing your full name below and clicking Confirm Signature, you certify that all the information in the application and your signature is accurate and true. Parent/Guardian Signature: Date