Early Childhood Programs Application Form Page 3
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4The Campagna Center
Early Childhood Programs
Child Information
Child’s First Name: __________________
MI:______
Last Name:_____________________
Preferred Site 1: _____________
Preferred Site 2: ____________
Preferred Site 3: ________________
**If no bus transportation is available, are you willing to transport?
Yes
No
**Will you be requiring extended care services?
Yes
No
Before School (7:30-8:30)
After School (3:00-6:00)
Both
Child is receiving a childcare subsidy (Voucher or Contracted Slot)
Gender:
Male
Female
*Birth Date: __________________
*Primary Language: ______________________________
*Other Language: ______________________________
Speaks English?:
Yes
No
English Skills:
Very Well
Well
Not Well
Not at All
*Ethnicity:
Latino *Race:
Asian
Bi-Racial/Multiracial
lack
Caucasian
Native American
Pacific Islander
Other
Unspecified
US Citizen?:
Yes
No
Eligibility Information
*Parental Status (check all that apply)
Two Parents
Single Parent
Teen Parent
Disabled Parent
Foster Parent
Active Male
Homeless
Guardian
Dual Custody
Student Parent
elation to Primary Caregiver _______________
Additional Eligibility Information
Does your child have a disability?
Yes
No
Does your child have an IEP/IFSP?
Yes
No
Type of Disability: __________________________________________________________
(Check all that apply)
CPS Referral
Domestic Violence Referral
Sibling of another child in HS/EHS
TANF
SSI
Pregnant Teen
Pregnant Woman (EHS only)
Rising Kindergartner
Other Information
____Father/father figure will participate in regularly scheduled activities designed for involvement in HS or EHS.
Child has a medical card?
Yes
No
Name of Insurance: ____________________________________
Medicaid #:
_______________________________________
If applicable:
2nd year application review – No changes needed (Parent Initials ______)
3rd year application review – No changes needed (Parent Initials ______)
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