Cattaraugus Wyoming Head Start: Apply Now

Apply Now

Please print and fill out the Paper Application and mail back to us, or fill out the information below.

* Child First Name

* Child Last Name

* Child Date Of Birth

Child Gender

* Child Address

* Child State

* Child Zip Code

Child County

* Primary Phone

Cell Phone

* Email

Parent Information

Mother/Guardian Name

Mother/Guardian Date Of Birth

Are you Pregnant yes
no

Due Date

Have You recieved Prenatal Care yes
no

Father/Guardian Name

Father/Guardian Date Of Birth

How did you hear about our program

Race and Ethnicity

Please Check Your Child's ethnicity and race. You are not required to answer this. No child will be discriminated against due to race, sex, color, national origin, age or disability

Ethnicity

Race

About Your Child

Do You have Concerns about Your Child

If yes, mark areas in which you have concerns below

Areas of Concern Speech/language Impairment
Health Impairment
Vision Impairment
Behavior
Physical Impairment
Developmental Delay
Social/Emotional
Hearing Impairment
other

Do Your child have an IEP or IFSP

Do Your child have an established medical diagnosois

If yes, what is your child's diability

Name of any Doctors, Specialist, clinics working with my child or family

Has your child attended Head Start or Early Head Start Before

If yes, which one

Where

Dates

Child Resides With

Number of adults in household

Number of children in household

Ages of Children

Does your child have health insurance

Child's Medicaid Number

Do you work or go to school

The next section must be completed

Income

Sources of Income Paycheck
Veterans Benefits
Social Security (Pension)
Unemployment
Supplemental Security Insurance (SSI)
Public Assistance?TANF
Child Support/Alimony

Other Income

Total Gross Income

Income Frequency

Total Gross Wages on Last years tax return

I understand that I need to submit proof of INCOME, CHILD’S BIRTHDATE and an IMMUNIZATION (SHOT) RECORD upon request. I further understand that this application does not guarantee that my child will be in Early Head Start or Head Start and/or that my child may be placed on a waiting list. PLEASE, review your application to make sure that all sections are complete. All information will be kept confidential. Head Start complies with all statutes relating to nondiscrimination.

* Parent/Guardian Signature

* Date

* Verify

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