Ready to Sign up? Leave this field blank Did an agency refer you to Head Start Yes No Agency Name & Person who referred: If an agency didn't refer you, how did you hear about Head Start of Yamhill County? A friend or family member Website Facebook Instagram Flyer Other If you answered "Other", please share how you heard about us. (optional) Is someone helping you complete this form? Yes No Primary Parent/Guardian First Name: Primary Parent/Guardian Last Name: Primary Parent/ Guardian Date of Birth: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Living in the home? Yes No Secondary Parent/Guardian First Name: (optional) Secondary Parent/Guardian Last Name: (optional) Secondary Parent/ Guardian Date of Birth: (optional) Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Living in the home? (optional) Yes No Living Address City State Zip Code Is Mailing Address the Same as Living Address? Yes No Mailing Address City State Zip Code Home Phone (optional) Cell Phone (optional) Message Phone (optional) Email Address (To receive submission confirmation) Family Structure 2 Parent Household 1 Parent Household 2 Grandparent Household 1 Grandparent Household Eligibility Information (Check all that apply) (optional) Parent is or was in foster care Parent(s)/Guardian(s) work in agriculture Parent/Guardian is or was in recovery Parent/Guardian is or was incarcerated Parent/Guardian is/has experienced Domestic Violence Member of the child's family is medically fragile Parent/Guardian is currently attending school Parent/Guardian does not have a high school diploma or GED Number of people in the family: Housing information: Own Home Renting Homeless, in a shelter or transitional housing, or living with friends or family Is parent or guardian expecting a child? (optional) Yes No Due date: Are you interested in Early Head Start? Yes No Does anyone in your household receive WIC? (optional) Yes No Primary Language English Other Please list primary language: Does parent speak English? Yes No Does child speak English? Yes No Is child in daycare? (School bus transportation is limited to certain centers and classes.) (optional) Yes No Address of Childcare: City: State: Zip Code: Days in childcare: Monday Tuesday Wednesday Thursday Is child in diapers or pull-ups during the daytime? (Potty trained is not required, but preferred for pre-K.) (optional) Yes No Applicant Child Information: Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Sex of Child Male Female Does the child have a diagnosed disability? Yes No Is the child on an IFSP? Yes No Is the child a foster child or in DHS custody? Yes (please submit placement letter in lieu of proof of income) No Please list all children in your family ages birth to 5. Would you like to add a second child ages 0-5 years? Yes No Child Information: Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Sex of Child Male Female Does the child have a diagnosed disability? Yes No Is the child on an IFSP? Yes No Is the child a foster child or in DHS custody? Yes (please submit placement letter in lieu of proof of income) No Add a third child age 0-5 years? Yes No Child Information Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Sex of Child Male Female Does the child have a diagnosed disability? Yes No Is the child on an IFSP? Yes No Is the child a foster child or in DHS custody? Yes (please submit placement letter in lieu of proof of income) No Please indicate which of the following DHS benefits you are receiving: TANF SNAP SSI// SSD or VA Compensation No receiving benefits I give my permission for HSYC to share my name and contact information with the school district, Yamhill County Public Health, A Family Place Relief Nursery, and/ or Migrant/ Tribal EHS and HS Programs for referrals to their parenting and child health/ preschool programs. Yes No The above information is true and complete, and I understand misrepresentation is considered fraud. Start drawing Clear Done Start over Date Signed: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2022 2023 2024 2025 Attach proof of income such as form 1040 from previous tax year, W-2 forms from previous tax year, or copy of most recent pay stub. For families with foster children, please submit their placement letter. (optional) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Proof of Income (2) (optional) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Send
