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Broome- Head Start Recruitment Form

Programs:

Head Start

By completing this form, it does not mean your child is registered for the Head Start Program. This form is used as a "Recruitment Form". For the application to be processed, we will also need: Copy of Child's Birth Certificate Verification of Family Income for the past year (i.e. consecutive pay stubs, W-2, etc) Proof of Residency Any Family Court documents relative to your Child

Complete the form below. Fields marked with * are required.

Agency Information

* Program Interested in:

Early Head Start (Birth- 3 years-old) Head Start (3-5 years old) Other CAP Program

Required

* Enrolling County:

Required

Enrolling Site:

Required

* How did you hear about us?:

Child Welfare Agency Family/Friend Local Community Agency Referral Physician/Dentist PSA Walk In Community Event Flyer from School Mailings Placemat Advertisement School District Website Community Partner Referral Flyers/Posters Other Posts/Banners/Lawn Signs Social Media Drive By Former Parent Other Head Start Public Ads State Preschool

Required

Primary Caregiver Information

* First and Last Name:

Required

Gender: (Primary Caregiver Information)

Required

Date of Birth: (Primary Caregiver)

Required

* Home Phone:

Required

Email Address:

Required

Mobile Phone:

Required

* Consent to receive text messages:

Yes No

Required

Work Phone:

Required

* Full Address: (include city, state )

Required

* Address Type:

Permanent Temporary Mailing

Required

* County:

Required

* School District:

Required

Household Information

* Family Structure:

Single Parent/Person Two-Parent/Persons

Required

* Matrital Status:

Married Single Divorced Widowed Separated Other

Required

* Parent(s)/Guardian(s) Best Descriptor:

Mother Father Parents Grandparent(s) Relative Other than Grandparent(s) Foster Parent(s) Other

Required

* Family Type:

Single Parent/Female Single Parent/Male Two-Parent Household Two-Parent Unmarried Single Person Two Adults (No Children) Non-Related Adults with Children Multigenerational Household Unknown/Not Reported Other

Required

* Number in Family: (Supported by PCG (Primary Caregiver's) Income)

Required

Number in Household: (Total number of people in home)

Required

Disabled: (Primary Caregiver)

Yes No

Required

* Received Mental Health Treatment?: (Primary Caregiver)

Yes No

Required

Health Insurance: (Primary Caregiver)

Yes No

Required

Insurance Type:

Required

Pregnant Mother before Enrollment: (EHS Pregnant Services ONLY)

Yes No

Required

Expected Delivery Date: (EHS Pregnant Services ONLY)

Required

* Current Housing:

Homeless Rent Own Other Other Permanent Housing Unknown/Not Reported

Required

* Current Housing Date:

Required

* Previous Housing:

Homeless Rent Own Other Other Permanent Housing Unknown/Not Reported

Required

Check all that Apply:

Moved in the last 24 months Maintained Independent Living Receive HEAP

Required

* Housing Type:

Apartment House Duplex Mobile Home Shelter Other

Required

* Housing Cost:

Required

Child Information

For Early Learning Program Enrollment ONLY

* Child 1- First and Last Name:

Required

* Child 1- Gender:

Required

* Child 1- DOB:

Required

Child 2- First and Last Name:

Required

Child 2- Gender:

Required

Child 2- DOB:

Required

Child 3- First and Last Name:

Required

Child 3- Gender:

Required

Child 3- DOB:

Required

Enrollment Information

* Does your Child take any medication?:

Yes No

Required

* Is your Child currently seeing a Health Care Provider for any on-going medical reason or treatment?:

Yes No

Required

* Are you able to transport your child to/from the center daily?:

Yes No

Required

Recruitment and Services

* Has your child previously been enrolled in Opportunities for Broome or Opportunities for Chenango?:

Yes No

Required

* Has the family previously been enrolled in Opportunities for Broome or Opportunities for Chenango CAP services programs?:

Yes No

Required

* How did you hear about our Agency?:

Required

Comments

Enter any additional Comments Here:

Required

Attach Documents

Copy of Child's Birth Certificate:

Required

Verification of Family Income for the past year: (Consecutive pay stubs, W-2, etc)

Required

Proof of Residency:

Required

Any Family Court documents relative to your Child:

Required

Other:

Required

Camera upload: (attach photos)

Add File

Required

Share Broome- Head Start Recruitment Form

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Broome Office

5 W. State Street Binghamton, NY 13901

PHONE: (607) 723-6493

FAX: (607) 723-6497

Chenango Office

44 West Main Street Norwich, NY 13815

PHONE: (607) 334-7114

FAX: (607) 336-6958

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This website is supported by Grant Number 02CH012141 and 02CH011631 from the Family and Youth Services Bureau within the Administration for Children and Families, a division of the U.S. Department of Health and Human Services. Neither the Administration for Children and Families nor any of its components operate, control, are responsible for, or necessarily endorse this website (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided). The opinions, findings, conclusions, and recommendations expressed are those of the author(s) and do not necessarily reflect the views of the Administration for Children and Families and the Family and Youth Services Bureau.

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Broome- Head Start Recruitment Form

Programs:

Agency Information

Primary Caregiver Information

Household Information

Child Information

Enrollment Information

Recruitment and Services

Comments

Attach Documents

Share Broome- Head Start Recruitment Form

Services

Family 3 Programs

Education 4 Programs

Nutrition 1 Program

Housing 12 Programs

Financial 4 Programs

Energy 1 Program

Phone App

All Programs

All Resources

Organization Info

About

History

Employment

Current Events

Reporting

Calendar

Contact

The Classic

Donate

Privacy Policy

Broome Office

5 W. State Street Binghamton, NY 13901

PHONE: (607) 723-6493

FAX: (607) 723-6497

Chenango Office

44 West Main Street Norwich, NY 13815

PHONE: (607) 334-7114

FAX: (607) 336-6958

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