The Campagna Center
Early Childhood Programs
Secondary Parent/Guardian Information
___ NO SECONDARY PARENT/GUARDIAN (skip section if no secondary parent/guardian)
Secondary Parent/Guardian First Name: __________________ MI:__________ Last Name: __________________
Gender:
Male
Female
*Birth Date: __________________
Primary Language: _________________________
Secondary Language: _____________________________
*Ethnicity:
Latino *Race:
Bi-Racial/Multiracial
Caucasian
Native American
Pacific Islander
Other
Unspecified
th
Education Level:
9
Grade or less
High School Graduate
Associate’s Degree
th
10
Grade
GED
Bachelor’s Degree
th
11
Grade
Training Certificate
Master’s Degree
th
12
Grade
Some College
Doctoral Degree
If in school/training, where? _______________________________________________________________________
Employment Status:
Employed full time
Employed part time
Self-employed
Retired or Disabled
Unemployed
Training or in school
Contact Information:
Employer/School Name: ___________________Work Phone Number: _______________________________________
Work Address: ___________________________City: _________________ State: ______ Zip Code: _____________
Home Address same as Primary Parent/Guardian
Home Address (if different than Primary Parent): _________________________________City: __________________
State: ______ Zip Code: ____________
Home Phone: _________________________
Cell Phone: ______________________
Email Address: _______________________________________
Does the Secondary Parent have Health Insurance?
Yes
No
Name of Insurance: ___________________________________________________
*Certification:
I certify that this information is true. If any part is false, my participation in the program may be terminated and I may be subject to
legal action. I also understand that the information in this application will be held in strict confidence within the program.
I further understand that this is an application for services that are paid for with federal funds and that intentionally providing
misleading, inaccurate or untruthful information of a material nature could result in un-enrolling my child from Head Start/Early
Head Start or VPI and could have serious legal consequences.
Parent Signature: _______________________________________
Date: _______________________
Parent Printed Name: ___________________________________