Central Montana Head Start Child Application

If you have a child that is 3 or 4 years of age by September 10th of the current enrollment year you may qualify for our Head Start Program.

Head Start is a full day program operating 8:00am-3:00pm, August through May.

The focus of the Head Start program is on kindergarten readiness. Families also receive home visits and family conferences. Transportation is not available.

Application Instructions

Please fill out this application completely. It contains important information that is used to determine your child’s eligibility for Head Start service. If you need help in completing the application, or have any questions, please call or come in to your local center.

*The following information may be helpful as you are completing the Application

General information: If you move or change your phone number after completing this application, it is your responsibility to notify Head Start. Please provide proof of your child’s date of birth with one of the following types of documents: Birth Certificate, hospital documentation, insurance card, and immunization record
Family size: Please list all people in the household who are supported by the family income.
Income and Eligibility: If your family is a current recipient of TANF benefits from DPHHS, SNAP benefits, receiving Supplemental Security Income (SSI), or providing foster care for the child you are applying for you do not need to provide income documentation. However, please provide current documentation of the benefits you are receiving or proof of foster care. If you are currently homeless, or have zero income, you do not need to provide documentation of income. Further documentation may be required.
Priority: Please fill out this page carefully – information you provide in this section will help us prioritize your child’s placement on the waiting list.
Affirmation: This affirmation must be signed and dated. Only a parent or legal guardian may sign this application. If parent or guardian intentionally falsifies documents or other eligibility information, their child will no longer be eligible for the program.

Please fill in the form completely and accurately. All information will be kept confidential. It will be used to help us determine if your family is eligible for Head Start services and to prioritize your placement. After completing the application, you will be contacted wither by phone or mail, regarding the status of your application. If you have any questions about this application, or need any help in completing it, please call us. We are happy to help!

For Child Applicant

Child’s First Name:

Child’s Middle Name:

Child’s Last Name:

Date of Birth:

Sex: Male Female

What language does your child speak most fluently? English Spanish Other

If Other, please specify:

What other Language does your child speak? English Spanish Other

If Other, please specify:

Attach proof of your child’s date of birth:

Parent or Guardian Information (The person signing the application should complete this section)

Parent or Guardian’s Name:

Date of Birth:

Relationship to child:

Address:

Address (City):

Address (State, ZIP):

My mail address is the same as my Physical address:

Mail Address

Mail Address:

Mail Address (City):

Mail Address (State, ZIP):

Telephone (Primary):

Cell:

Work:

Email Address:

In what language do you prefer to communicate? English Spanish Other

If Other, please specify:

Other Parent or Guardian Information:

Parent or Guardian’s Name:

Date of Birth:

Relationship to child:

Address:

Address (City):

Address (State, ZIP):

My mail address is the same as my Physical address:

Mail Address

Mail Address:

Mail Address (City):

Mail Address (State, ZIP):

Telephone (Primary):

Cell:

Work:

Email Address:

In what language do you prefer to communicate? English Spanish Other

If Other, please specify:

FAMILY SIZE AND INCOME

By law, Central Montana Head Start may provide services only to families: 1) with a family income at or below the Federal Poverty Guidelines; 2) who are receiving certain forms of public assistance; 3) who are applying on behalf of a foster child; 4) who are currently homeless. Central Montana Head Start may also serve a limited number of families with a child with special needs who would not otherwise qualify for the program.

Family Size

In order to determine if your income is at or below the Federal Poverty Guidelines, we must know how many people are living in your household, as well as your family income. For our purposes, a family is “all persons living in the same household who are: 1) supported by the income of the parent(s) or guardian(s) of the child enrolling in the program and 2) related to the parent(s) or guardian(s) by blood, marriage, or adoption.”

Race:
B= Black/African American
W= White
N= American Indian
A= Asian
P= Native Hawaiian/ Other Pacific Islander
H= Hispanic/Latino
BM= Biracial/Multiracial (list all that apply)
- American Indian/Alaska Native
- Asian
- Black/African American
- Native Hawaiian/ other Pacific Islander
- Hispanic/Latino
- White
U= Unspecified
Ethnicity: Hispanic or Latino
Non-Hispanic or Non-Latino

Education:

G09= Grade 9 or less
G10= Grade 10
G11= Grade 11
G12= Grade 12 (but did not graduate)
HSG= High school graduate
GED= GED
COL= Some College
A= Associates Degree
B= Bachelor’s Degree
M= Master’s Degree

Employment Status:
(Put all that apply)

U= Unemployed
F= Full Time Employment
P= Part Time Employment
FS= Full Time Student
PS= Part Time Student
S= Seasonal Employment
R= Retired
D= Disabled

Example: FS/P
Means that you are a full time student, but have part time employment.

Please list ALL family members and persons living in your home including the applicant.

How many family members and persons live in your home, including the applicant?

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

Last Name:

First Name:

Relationship to Child:

Date of Birth:

Sex:

Race:

Ethnicity:

Education:

Employment:

ELIGIBILITY

If you answer “Yes” to any of the eligibility questions, you are automatically income eligible for Head Start services. You will be asked to provide verification(s). Please have attachments ready.

Is your family currently receiving TANF benefits? Yes No

Are you or anyone in your family currently receiving Supplemental Security Income (SSI)? Yes No

Are you or anyone in your family currently receiving SNAP benefits? Yes No

Is this application for a foster child placed with you through the State of Montana? Yes No

Is your family currently homeless? Yes No

Attach verification documents for the above questions marked Yes.

FAMILY INCOME

Income (see definitions below) must include total income of all family members of the family listed above for either the past twelve months or for the previous calendar year, whichever more accurately reflects your family’s current situation.

I have attached one or more of the following required documents for income verification.

Pay Stubs for the relevant time period

W-2 form for the preceding year

Individual Income Tax Form 1040 for the preceding year

Written Statement From Employer/Pay Envelopes

Attach verification documents for the above questions marked.

I have attached one of the following additional types of income verification

Self-declaration (homeless/zero income) Verify with 3rd party if possible.

Child Support Information/Alimony

Social Security/TANF/SNAP Documentation

Financial Aid Award/ Pell Grant Letter

Attach verification documents for the above questions marked.

HEAD START PROGRAM DEFINITION OF INCOME: Income means total cash receipts before taxes from all sources, with certain exceptions. Income includes 1) money, wages, or salary before deductions; 2) net income from non-farm self-employment; 3) social security or railroad retirement; 4) unemployment compensation, strike benefits, worker’s compensation, veterans benefits, or public assistance; 5) training stipends; 6) alimony, child support, military family allotments, other regular support from absent family member or someone not living in the household; 7) private pensions, government pensions, including military retirement, insurance or annuity payments; 8) college scholarships, grants, fellowships, assistantships; 9) dividends, interest, net rental income, net royalties, receipts from estates or trusts; 10) net gambling or lottery winnings.

OTHER INFORMATION

Are you currently receiving assistance from any other agency? (Check all that apply) Energy Assistance/ LIEAP Subsidized Housing/ Section 8 WIC None

Is your child currently receiving medical or dental coverage through Healthy Montana Kids or Healthy Montana Kids Plus? (check which program applies) Healthy Montana Kids Healthy Montana Kids Plus None

Are you a joint custody family? Joint custody means care and support is shared between both parents who are residing in separate households. Yes No

Do you have a parenting plan? Yes No

Do you have a Temporary Restraining Order (TRO), Parenting Plan, or court papers regarding custody? Yes No

PRIORITY

The following information will be used to prioritize your placement. Please check all family factors and/or concerns that apply.

Please indicate any factors that apply.

Unemployed

Referral from other Agency/ Professional

Child of a Head Start Staff

Family health problems/disability

Grandparent or Kinship care

Mental Health- child and/ or Parent/Guardian

Biological Mother below age 18 when child was born

Single Parent home

Family in transition

Education level- 8th grade level or lower

Previous head start family

None

DIAGNOSED DISABILITIES

To provide the best placement for your child, please indicate any disabilities that have been diagnosed for which your child is receiving Early Childhood Special Education Services.

Please indicate any factors that apply.

Autism

Emotional/ behavior disorder

Speech or language disorder

Development delay

Occupational/ physical therapy

My child has a current IEP/IFSP

None

CURRENT FAMILY CIRCUMSTANCES

Please indicate any factors that apply.

Child abuse or neglect (has work with DFS)

Death in the family

Divorce

Domestic violence

Substance abuse

Incarceration of a parent or guardian

Parental development disability

Parent, guardian or child needs interpreter

Need a medical or dental provider

Emergency / crisis situation

No Transportation

Significant medical bills and not receiving insurance

Military deployment

Sibling with documented disability

None

AFFIRMATION

Under penalty of perjury, I affirm that I am the parent or legal guardian of the child applying for Head Start, and that, to the best of my knowledge, all of the information that I have provided is complete and correct. I understand that if I deliberately misrepresent my family circumstances, my family may not be eligible for further services.

I have read and agree to the above Affirmation statement:

Thank you for submitting your CMHS Child Application! You will be contacted wither by phone or mail regarding the status of your application. If you have any questions about this application, or need any help in completing it, please call us. We are happy to help!

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