Application Miami-Dade Community Action And Human Services Department Head Start / Early Head Start Family Information (Page 4 of 6) in pdf

Miami-Dade Community Action and Human Services Department

Head Start / Early Head Start

Family Member Information

Primary Adult (Parent/Legal Guardian):

Last

First

Middle

Birthday

Gender

□

Lives with Family

Custody

Provides Financial Support

Teen Parent

Employment Status:

Race:

Education:



 Asian

Full Time

Full Time & Training

 Associates

Bachelors  Masters



 Black or African American

Part Time

Part Time& Training

 American Indian or Alaskan Native



Retired

Disabled

 College Degree/Training

 Native Hawaiian or other Pacific Islander



 US Military

Training or School

 White



 College Degree or advance Training

Seasonally Employed



Unemployed

Ethnicity:

 9

grade or less 10

grade  11

grade 12

English Proficiency:

 Hispanic or Latino Origin

Grade

 None

 Poor  Moderate  Proficient

 Non-Hispanic or Latino Origin

 High School

Other Language Spoken:________________

 None

 Poor  Moderate  Proficient

Secondary Adult (Parent/Legal Guardian):

Last

First

Middle

Birthday

Gender

□

Lives with Family

Custody

Provides Financial Support

Teen Parent

Employment Status:

Race:

Education:



 Asian

Full Time

Full Time & Training

 Associates

Bachelors

 Masters



 Black or African American

Part Time

Part Time& Training

 American Indian or Alaskan Native



Retired

Disabled

 College Degree/Training

 Native Hawaiian or other Pacific Islander



 US Military

Training or School

 White



 College Degree or advance Training

Seasonally Employed



Unemployed

Ethnicity:

 GED  9

grade or less 10

grade  11

grade

English Proficiency:

 Hispanic or Latino Origin

12

Grade

 None  Poor

 Moderate

 Proficient

 Non-Hispanic or Latino Origin

Other Language Spoken:_______________

 9

grade or less  High School

 None  Poor

 Moderate

 Proficient

Other Family Members

(Supported by the income of parent or guardian):

Adult/Child

Last

First

Birthday

Gender

Relationship

Application/ Referral Source (required):

Child Development Services Child Welfare Agency Community Outreach Court Ordered Referral Department of Children & Families

Disability Program Early Head Start Family/Friend Flea Market Former Parent Hospital/Health Clinic Healthy Start Hotline Public

Housing Public or Private Non-Profit Organization Public Schools Resource & Referral Agency Self Referral South Florida Workforce

Unemployment WIC Youth Fair  Other (specify):___________________________________________

Verification (signature required):

Please Read Before Signing

I certify that the information provided in this application package, and the proof of income provided for enrollment eligibility, is accurate

and truthful to the best of my knowledge. Providing false income/information could result in dismissal from the program.

Parent or Guardian Signature: ______________________________________________

Date: _____/_____/_____

Parent or Guardian Print Name: ____________________________________________

Miami Dade CAA Head Start / EHS – December 2012

Page 2

Application Miami-Dade Community Action And Human Services Department Head Start / Early Head Start Family Information Page 4

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