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ENROLL CHILD

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Pre-Application Klamath Family Head Start

Head Start: To apply your child must be 3 or 4 by September 1st.

Early Head Start: To apply your child must be 0-3 or you must be a pregnant mother.

Pre-Application Klamath Family Head Start

Company
This field is for validation purposes and should be left unchanged.
Which site are you applying for?*
- Klamath Falls (Main and Town & Country Sites)
- Merrill
- Bonanza
- Lakeview
How did you hear about our program?
Primary Adult's Full Name:*
First Last
Is this a pregnant mother applying?*
- Yes
- No
Primary Adult's Date of Birth:*
Month
Day
Year
Primary Adult's Gender:*
- Male
- Female
Primary Adult's Relationship to Applying Child:*
Primary Adult's Phone:*
Primary Adult's Email:*
Primary Adult's Race:*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Hispanic or Latino
Primary Adult's Employment Status:*
- Full Time
- Part Time
- Retired / Disabled
- Enrolled in School
- Seasonally Employed
- Unemployed
Primary Adult's Education Level:*
- Grade 9 or less
- Grade 10
- Grade 11
- High School Graduate
- GED
- Some College
- College Degree/Certificate
- AA
- BA/BS
- MS
Does the Primary Adult live at the child's primary residence?
- Yes
- No
- Shared Custody
Secondary Adult's Full Name:
First Last
Secondary Adult's Date of Birth:
Month
Day
Year
Secondary Adult's Gender:
- Male
- Female
Secondary Adult's Relationship to Applying Child:
Secondary Adult's Phone:
Secondary Adult's Email:
Secondary Adult's Race:
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Hispanic or Latino
Secondary Adult's Employment Status
- Full Time
- Part Time
- Retired / Disabled
- Enrolled in School
- Seasonally Employed
- Unemployed
Secondary Adult's Education Level:
- Grade 9 or less
- Grade 10
- Grade 11
- High School Graduate
- GED
- Some College
- College Degree/Certificate
- AA
- BA/BS
- MS
Does the Secondary Adult live at the child's primary residence?
- Yes
- No
- Shared custody
Full Legal Name of Child Applying:*
If pregnant mother, please put N/A.
Child's Date of Birth:*
Month
Day
Year
Child's Gender:*
- Male
- Female
Child's Race:*
- American Indian or Alaska Native
- Asian
- Black or African American
- Native Hawaiian or other Pacific Islander
- White
- Hispanic or Latino
Name of Child's Health Insurance:
Child's Doctor/Medical Clinic:
Child's Dentist/Dental Clinic:
Child's Known Food Allergies:
Does your child experience any of the following medical conditions?
- Asthma
- Seizures
- Glasses/Vision Issues
- Problems with Hearing
- Diabetes
- Allergy requiring Epi-Pen
- None
Are you able to transport your child to school? (Only available for 3-5 year old classes in Klamath Falls.)*
- Yes
- Yes, but would prefer bus transportation
- No, will need bus transportation to attend
Is your child potty trained? (Not required to enroll.)
- Yes
- No
- Almost
Does your child nap during the day?
- Yes
- No
- Sometimes
Are there custody arrangements in place for this child?*
- Yes
- No
If applying for more than one child, please type their Full Names and Dates of Birth:
Full Names and Dates of Birth of other children in your home that you are NOT applying for:
Primary Language in Family*
- English
- Spanish
- Other
If Other, what language?
Does your Child Have an IFSP/receiving services from Early Childhood Intervention? If so, we require your permission to share information with ECI to coordinate child services.*
- Yes
- No
Living Address:*
Street Address Address Line 2 City State ZIP Code
Are your living address and mailing address the same?
- Yes
- No
Mailing Address
Street Address Address Line 2 City State ZIP Code
Are you receiving any of the following benefits or services?*
- SSI
- TANF
- WIC
- SNAP
- HUD
- KBBH
- Early Childhood Intervention
- Child Support
- Unemployment Benefits
- Scholarships / Grants
- No Income
- None
If no income, how have your family’s needs been provided for the last year?
How has your family’s housing been provided in the last year?
Emergency Contact's Full Name:
Emergency Contact's Phone:
Emergency Contact's Relationship to Child:
Is there anything else about your family or child you would like us to know?
A Head Start staff member will contact you to set up an interview. What are the best times/days to contact you?
Please sign that your application is true and complete to the best of your knowledge:
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Klamath Family Head Start provides equal opportunity and access to all services and/or employment to every person. We do not discriminate on the basis of race, religion, gender, ethnicity, cultural background, age, disabilities or sexual preference, or any other legally protected class or status. For further information regarding compliance under this policy, contact Human Resources Director who serves as the Title VI, VII, IX, and section 504 Compliance Coordinator at 541-882-5988
TTY/TDD 1-800-833-3232.