Enrollment Application Program Option(Required) Early Head Start prenatal to age 3 Head Start ages 3 to 5 School Year(Required) 2025-2026 2026-2027 Location:(Required) Anamoose Devils Lake Granville Harvey Rugby Towner Applicant InformationName (Child or expectant mother)(Required) First Name (Child or expectant mother)Date of Birth(Required) Gender(Required) Male Female Due Date Due Date (prenatal applicants only)Race(Required) African American American Indian Asian Caucasian Native Hawaiian or Pacific Islander I prefer not to specify Other (please specify) Race (please check all that apply)Hispanic/Latino(Required) Central American Cuban Mexican/Chicano Puerto Rican Not Hispanic/Latino I prefer not to specify Other (please specify) Hispanic/Latino (please check all that apply)Other (Race)Other (Hispanic/Latino)Primary Language:(Required)EnglishSpanishIndigenous/TribalAmerican Sign LanguageChineseFrenchGermanJapaneseUkranian/RussianOtherIs your family learning another language in addition to English?(Required) Yes No Secondary Language:EnglishSpanishIndigenous/TribalAmerican Sign LanguageChineseFrenchGermanJapaneseUkranian/RussianOtherHas your child ever attended childcare before?(Required) Yes No Are you currently in need of childcare?(Required) Yes No Need of childcare?(Required) Part-time Full-time Does your child currently have medical coverage?(Required) Yes, Medicaid Yes, Private Insurance No Medicaid Number/Insurance Policy NumberInsurance Policy NumberInsurance Policy Holder Name and BirthdateDo you have any concerns about your child’s development, health or nutrition?(Required) Yes No Visual Impairment Concern Diagnosed ADD/ADHD Concern Diagnosed Hearing Impairment Concern Diagnosed Autism Concern Diagnosed Health/Orthopedic Impairment Concern Diagnosed Traumatic Brain Injury Concern Diagnosed Speech or Language Impairment Concern Diagnosed Non-Categorical Delay Concern Diagnosed Allergies (nutritional and/or environmental) Concern Diagnosed Please explain:Other: Concern Diagnosed Please explain:Family InformationPhysical Address(Required) Street Address City State ZIP / Postal Code Physical Address (Where applicant is living)Mailing Address Street Address City State ZIP / Postal Code Mailing Address (If different)Who is the applicant living with?(Required) Mother Father Aunt Stepmother Stepfather Uncle Grandmother Grandfather Foster Parent(s) Other/Homeless (please explain) Other (Who is the applicant living with?)(Required)Primary Parent/Guardian Name(Required)Date of Birth(Required) Does this person have custody?(Required) Yes No Cell Number(Required)Work NumberHome/Other NumberEmail Address(Required) Education – Highest Completed(Required) Less than High School High School Diploma/GED Some College (no degree) Associate degree Bachelor’s Degree or higher Current Employment Status(Required) Full Time (32 hours/week +) Part Time Unemployed Retired/Disabled Other Please explain(Current Employment Status)Race (PP)(Required) African American American Indian Asian Caucasian Native Hawaiian or Pacific Islander I prefer not to specify Other (please specify) Race (please check all that apply)Hispanic/Latino (PP)(Required) Central American Mexican/Chicano Cuban Puerto Rican Not Hispanic/Latino I prefer not to specify Other (please specify) Hispanic/Latino (please check all that apply)Other (Race)Other (Hispanic/Latino)Are you currently attending school?(Required) Yes No Are you a member of the United States military on active duty?(Required) Yes No Are you a veteran of the United States military?(Required) Yes No Secondary Parent/GuardianNameDate of Birth(Required) Is this person living in the home?(Required) Yes No Does this person have custody?(Required) Yes No Cell Number(Required)Work NumberHome/Other NumberEmail Address(Required) Education – Highest Completed(Required) Less than High School High School Diploma/GED Some College (no degree) Associate degree Bachelor’s Degree or higher Current Employment Status(Required) Full Time (32 hours/week +) Part Time Unemployed Retired/Disabled Other Please explain(Required)(Current Employment Status)Race (SP)(Required) African American American Indian Asian Caucasian Native Hawaiian or Pacific Islander I prefer not to specify Other (please specify) Race (please check all that apply)Hispanic/Latino (SP)(Required) Central American Mexican/Chicano Cuban Puerto Rican Not Hispanic/Latino I prefer not to specify Other (please specify) Hispanic/Latino (please check all that apply)Other (Race)Other (Hispanic/Latino)Are you currently attending school?(Required) Yes No Are you a member of the United States military on active duty?(Required) Yes No Are you a veteran of the United States military?(Required) Yes No Please list all of the applicant’s siblings:NameGender Male Female Date of Birth Does this child live in the home? Yes No NameGender Male Female Date of Birth Does this child live in the home? Yes No NameGender Male Female Date of Birth Does this child live in the home? Yes No NameGender Male Female Date of Birth Does this child live in the home? Yes No NameGender Male Female Date of Birth Does this child live in the home? Yes No Number of adults (18 years or older) in the household:(Required)Number of children (under 18 years) in the household:(Required)Many families receive services or financial assistance from one or more programs or agencies. Does your family receive services from any of the following services:(Required) Medicaid SNAP/TANF Energy Assistance/LIHEAP Unemployment Insurance Public Housing Assistance Supplemental Security Income (SSI) WIC Health Tracks Child Care Assistance Foster Care/Adoption Subsidy Other: None of these Other (services)Is your family experiencing a crisis or unmet family needs? Yes No If yes, please explain:Were you referred to our program? Yes No If yes, by whom: Please include a copy of your child’s birth certificate and proof of income for each parent/guardian in the home. These items are required to process this application. Acceptable forms of income verification include: • Paystubs • W-2’s • Income Tax Form 1040 (page 1 only) • SNAP/TANF/SSI Benefits • Child Support • Unemployment Benefits • Foster Care Documentation _________________________________________________________________________ Your family's income may be adjusted if your housing costs exceed 30% of your total gross income. This step is optional and will not affect the processing of your application. Acceptable forms of housing expense verification include: • Rent/Mortgage • Homeowner’s/Renter’s Insurance • Mortgage Interest • Property Taxes Utilities: • Gas/Propane • Water • Sewer • Trash • Electricity Birth Certificate (new applicants only)Max. file size: 256 MB. Income Verification (all applicants)Max. file size: 256 MB. Birth Certificate Drop files here or Select files Max. file size: 256 MB, Max. files: 20. Income Verification Drop files here or Select files Max. file size: 256 MB, Max. files: 20. Housing Costs Drop files here or Select files Max. file size: 256 MB, Max. files: 20. Parent/Guardian Signature(Required)Date(Required) Parent/Guardian SignatureDate Consent(Required) By signing, I certify that the information provided is true and complete to the best of my knowledge. I understand that all information will remain confidential and will be used solely for the benefit of our child and family and will not be shared without my permission. I further understand that this application is for services that are paid for with federal funds and that intentionally providing misleading, inaccurate or untruthful information could result in the disenrollment of my child from Early Head Start/Head Start and could have serious legal consequences for me.(Required)
