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The Neighborhood Place for Early Head Start A division of the Early Learning Coalition of Miami-Dade/Monroe
6251 NW 7th Avenue Suite 204 Miami, Florida 33150 (305) 646-7220 ext. 2457
(REVISED 4/1/2020)
Thank you for your interest in The Neighborhood Place for Early Head Start Program (TNPEHS). Our program offers full day preschool and family services at various locations throughout Miami-Dade County. To qualify for our services, your child must be age and income eligible. Submitting this application does not guarantee acceptance into Early Head Start, priority will be given based on a point system. ELIGIBILITY REQUIREMENTS Age Eligibility: For Early Head Start - Your child must be under 3 years of age. Income Eligibility: Your family is income eligible if your income meets 100% of the 2020 Federal Income Guidelines:
For families/households with more than 8 members, add $4,480 for each additional person. SUBMITTING YOUR APPLICATION Once you have completed the application, you may submit your materials in one of the following ways:
Visit the Central Service Center, United Way Building, 3250 SW 3rd Avenue, Miami, Florida 33129 Visit the North Service Center, Golden Glades Office Park, 1515 NW 167 th Street, Suite 320 Miami Gardens, Florida 33169
Visit the South Service Center, The Centre at Cutler Bay Condominium, 18951 SW 106 Ave, Unit B-208, Miami, Florida 33157 Visit the Edison Office, Edison Marketplace, 6251 NW 7th Avenue, Ste. 204, Miami, Florida 33150
You will be contacted by email once your application has been processed.
SIZE OF FAMILY UNIT GROSS ANNUAL INCOME
1 $ 12,760
2 $ 17, 240
3 $ 21,720
4 $ 26,2005 $30,680
6 $35,1607 $39,6408 $44,120
Visit the Provider of your choice to complete an application for services.
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2019-2020 Selection Criteria
Criteria Points
A. Income
Low Income 0 – 25% of the Poverty Guidelines 100
Low Income 26% – 50% of the Poverty Guidelines 95
Low Income 51% –75% of the Poverty Guidelines 85
Low Income 76% – 100% of the Poverty Guidelines 75
B. Age
0 - 11 months 150
12 months – 2 years old 100
2 years and 1 month – 3 years old 80
C. Disability
Diagnosed Disability with IFSP 375
Condition Diagnosed by a Professional 230
Identified as having concerns through a screener by qualified professional 50
Parental Concern 50
D. School Readiness
BG-8 250
BG-5 230
BG-3 200
BG-1 175
Waitlisted applicants 100
E. Parental Status
Foster Parent 100
Legal Guardian 95
One Parent Family 90
Two Parent Family 60
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F. Other Factors
Documented Homeless 230
Documented Incarcerated Parents 150
Documented SSI/TANF Recipients 150
Families with prior DCF history 100
Documented Disaster Evacuee 100
Documented Impacted by Gun Violence 100
Documented Substance Abuse 90
Documented Domestic Violence 90
Documented DCF Referral and Court Order 90
Undocumented Domestic Violence referred by partnering agency 50
Referral from partnering agency 50
Documented Student 80
Documented Working Parent 80
Documented Teen Parent 75
Documented Sibling of Returning Student 75
Documented Migrant Seasonal Farm Worker 75
Documented Public Housing Resident 75
Documented Infant Mortality 50
Documented Pregnant Woman 50
Postpartum Depression 50
Enrolled in Current Center 50
The Neighborhood Place for Early Head Start A division of the Early Learning Coalition of Miami-Dade/Monroe
EHS PARTNERS BY COMMUNITIES
NORTH Liberty City
It’s a Small World Learning Center II 3100 NW 94th Street 33147 (305) 696-1234
It’s a Small World Learning Center VII 8601 NW 22nd Avenue 33147 (305) 691-2665
Liberty Academy Daycare and Preschool, Inc. 7750 NW 12th Avenue 33150 (305) 696-8100
Lincoln Marti 10203 NW 21st Court 33147 (305) 693-2225
LORD’s Learning Center, Inc. 17 NW 84th Street 33150 (305) 756-6119
Sheyes of Miami Day Care #3 4801 NW 7th Avenue 33127 (305) 754-4087
Sheyes of Miami Learning Center 3038 NW 48th Terrace 33142 (305) 634-6268
Shores School 545 NW 95th Street 33150 (305) 751-0101
Step Above Academy 750 NW 96th Street 33150 (305) 836-5723
The Carter Academy 10200 NW 22nd Avenue 33147 (305) 693-3555
The Carter Academy II 1910 NW 95th Street 33147 (305) 342-3448
Wynwood Learning Center II 5580 NW 7th Avenue 33127 (305) 603-8865
Opa-Locka
America’s Little Leader Christian Academy 2570 NW 152nd Terrace 33054 (786) 332-4698
Cambridge Academy & Camp Learning Center, Inc. 2750 NW 167th Street 33054 (305) 625-5437
Children of the Sun Academy, Inc. 1360 Kasim Street 33054 (305) 688-9088
Little Ones Academy 2527 Opa-Locka Boulevard 33054 (786) 238-7005
Miami Gardens Learning Center 16600 NW 25th Avenue 33054 (305) 623-4000
Pink and Blue Children’s Academy 1840 NW 152nd Terrace 33054 (305) 681-0616
SOUTH Little Havana
Kids Small World Learning Center 3360 W Flagler Street 33135 (305) 567-0661
Lincoln Marti 450 SW 16th Avenue 33135 (305) 643-2626
Lincoln Marti 905 SW 1st Street 33130 (305) 325-2000
Rainbow Intergenerational Learning Center 700 SW 8th Street 33130 (305) 285-3263
Hialeah New Aladdin Learning Ceter 5932 W 16th Avenue 33012 (305) 362-0016
Springview Academy of Hialeah 55 W 29th Street 33012 (305) 381-5768
Homestead Little Red School House of Homestead 159 NE 9th Street 33030 (305) 248-2229
My Little Angels Daycare Center 280 S Krome Avenue 33030 (305) 242-3646
Naranja Prep Academy Annex 310 NE 2nd Drive 33030 (786) 601-9560
Florida City Kinderkids Academy III 40 NW 5th Avenue 33034 (786) 339-9244
Kinderland 4 Kids, LLC 35 SW 6th Avenue 33034 (786) 243-2556
Our Little Hands of Love, Inc. 489 W Lucy Street 33034 (305) 248-6222
Precious Moments Learning Center 580 Davis Parkway 33034 (305) 245-5954
Early Head Start Enrollment Application
Page 1 of 10
INSTRUCTIONS: Please carefully read and accurately complete every section of this application. Anything that does not apply to you write “N/A”. Applications with incomplete, false, or inaccurate information will not be entered in the system or considered for selection. Please be advised that providing false information or income omissions may be grounds for rejection of this application or termination of childcare services.
APPLICATION DATE:
LOCATION (SCHOOL) PREFERENCE: (Note - if you do not select any school you will not be placed on a waiting list anywhere)
Choice #1 Choice #2 Choice #3
APPLICANT (Child’s Information)
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
*RACE: *ETHNICITY:
☐ American Indian/Alaskan ☐ Asian ☐ Black/African American
☐ Pacific Islander/Hawaiian ☐ White
☐ Other (Bi-Racial/Multiracial):
☐ Hispanic/Latino
☐ Non-Hispanic/Non-Latino
ENGLISH PROFICIENCY:
☐ None/Nonverbal ☐ Little ☐ Moderate ☐ Proficient
OTHER LANGUAGE (SPECIFY):
OTHER LANGUAGE PROFICIENCY:
☐ Little ☐ Moderate ☐ Proficient
*PRIMARY HEALTH COVERAGE: ☐ Children’s Health Insurance Program (CHIP) – FL Kid Care ☐ Combined Medicaid/CHIP
☐ Medicaid ☐ No Insurance ☐ Private Health Insurance
☐ State-Only Funded Insurance ☐ Other:
OTHER HEALTH COVERAGE: ☐ Children’s Health Insurance Program (CHIP) – FL Kid Care ☐ Combined Medicaid/CHIP
☐ Medicaid ☐ No Other Insurance ☐ Private Health Insurance
☐ State-Only Funded Insurance ☐ Other:
MEDICAID ELIGIBILITY STATUS: ☐ Not Eligible ☐ On Medicaid ☐ Potentially Eligible
INSURANCE OR MEDICAID NUMBER:
*NAME OF DOCTOR/MEDICAL HOME:
DOCTOR/MEDICAL PHONE NUMBER:
DENTAL COVERAGE: ☐ Children’s Health Insurance Program (CHIP) – FL Kid Care ☐ Combined Medicaid/CHIP
☐ Medicaid ☐ No Insurance ☐ Private Health Insurance
☐ State-Only Funded Insurance ☐ Other:
DENTAL COVERAGE NUMBER:
*NAME OF DENTIST/DENTAL HOME:
DENTIST/DENTAL PHONE NUMBER:
Do you live in Miami-Dade County? Are you currently homeless? Does your child have a diagnosed disability and has an IFSP?
☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
Is child enrolled in School Readiness?
If yes, what date did you become eligible?
What is your School Readiness expiration date?
If not enrolled in School
Readiness, have you applied?
If yes, what date did you apply?
☐ Yes ☐ No ☐ Yes ☐ No
Early Head Start Enrollment Application
Page 2 of 10
FAMILY MEMBERS
PRIMARY ADULT
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
*RACE: *ETHNICITY:
☐ American Indian/Alaskan ☐ Asian ☐ Black/African American ☐ Pacific Islander/Hawaiian
☐ White ☐ Other (Bi-Racial/Multiracial):
☐ Hispanic/Latino
☐ Non-Hispanic/Non-Latino
EMAIL ADDRESS:
ENGLISH PROFICIENCY:
☐ None ☐ Little ☐ Moderate ☐ Proficient
OTHER LANGUAGE (SPECIFY): OTHER LANGUAGE PROFICIENCY:
☐ Little ☐ Moderate ☐ Proficient
*HIGHEST GRADE
COMPLETED: ☐ Less than high school ☐ Some college ☐ Associates Degree
☐ Some High School (specify grade completed): _____ ☐ Advance Training ☐ Bachelor’s Degree
☐ High School Grad ☐ Training Certificate ☐ Master’s Degree
☐ GED ☐ Doctoral Degree
*EMPLOYMENT: ☐ Full-time & Training ☐ Full-time (35 hrs/wk or more)
☐ Part-time & Training ☐ Part-time (less than 35 hours) ☐ Training or School
☐ Retired or Disabled ☐ Seasonally Employed ܆ ☐ Unemployed
RELATIONSHIP TO CHILD: ☐ Biological/Adopted/Step ☐ Foster ☐ Grandchild ☐ Other/Other Relative (specify):
MARITAL STATUS LEGAL CUSTODY LIVES WITH
FAMILY
PROVIDES FINANCIAL
SUPPORT
TEEN PARENT INCARCERATED
PARENT
☐ Married ☐ Single ☐ Widow ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
SECOND ADULT
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
*RACE: *ETHNICITY:
☐ American Indian/Alaskan ☐ Asian ☐ Black/African American ☐ Pacific Islander/Hawaiian
☐ White ☐ Other (Bi-Racial/Multiracial):
☐ Hispanic/Latino
☐ Non-Hispanic/Non-Latino
EMAIL ADDRESS:
ENGLISH PROFICIENCY:
☐ None ☐ Little ☐ Moderate ☐ Proficient
OTHER LANGUAGE (SPECIFY): OTHER LANGUAGE PROFICIENCY:
☐ Little ☐ Moderate ☐ Proficient
*HIGHEST GRADE
COMPLETED: ☐ Less than high school ☐ Some college ☐ Associates Degree
☐ Some High School (specify grade completed): _____ ☐ Advance Training ☐ Bachelor’s Degree
☐ High School Grad ☐ Training Certificate ☐ Master’s Degree
☐ GED ☐ Doctoral Degree
*EMPLOYMENT: ☐ Full-time & Training ☐ Full-time (35 hrs/wk or more)
☐ Part-time & Training ☐ Part-time (less than 35 hours) ☐ Training or School
☐ Retired or Disabled ☐ Seasonally Employed ܆ ☐ Unemployed
RELATIONSHIP TO CHILD: ☐ Biological/Adopted/Step ☐ Foster ☐ Grandchild ☐ Other/Other Relative (specify):
MARITAL STATUS LEGAL CUSTODY LIVES WITH
FAMILY
PROVIDES FINANCIAL
SUPPORT
TEEN PARENT INCARCERATED
PARENT
☐ Married ☐ Single ☐ Widow ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
Page 3 of 10
Early Head Start Enrollment Application
LIST ADDITIONAL FAMILY MEMBERS SUPPORTED BY THE HOUSEHOLD INCOME
(ADDITIONAL MEMBERS SUPPORTED BY THE HOUSEHOLD INCOME CAN BE ADDED ON PAGE 7)
1.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
2.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
3.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
FAMILY INFORMATION
LIVING ADDRESS:
CITY: STATE: ZIP CODE: COUNTY:
MAILING ADDRESS:
CITY: STATE: ZIP CODE: COUNTY:
PHONE #: TYPE: WHOSE NUMBER
☐ Cell ☐ Home ☐ Work
PHONE #: TYPE: WHOSE NUMBER
☐ Cell ☐ Home ☐ Work
PHONE #: TYPE: WHOSE NUMBER
☐ Cell ☐ Home ☐ Work
*PARENTAL STATUS: *PRIMARY LANGUAGE SPOKEN AT HOME: *IS THE FAMILY HOMELESS? *REFERRED BY CHILD WELFARE AGENCY
(specify)?
☐ One Parent Family
☐ Two Parent Family
☐ Yes ☐ No
*AT LEAST ONE
PARENT/GUARDIAN IS AN ACTIVE
MEMBER OF THE U.S. MILITARY?
*AT LEAST ONE PARENT/GUARDIAN
IS A VETERAN OF THE U.S. MILITARY?
*RECEIVING SNAP: *RECEIVING
WIC?
WIC NUMBER:
☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No
IS ANYONE IN THE FAMILY AN EMPLOYEE OF THE
EARLY LEARNING COALITION OF MIAMI- DADE/MONROE?
☐ Yes ☐ No IF SO, WHAT DEPARTMENT
DO YOU WORK:
IS ANYONE IN THE FAMILY RELATED TO AN EARLY
LEARNING COALITION OF MIAMI-DADE MONROE? ☐ Yes ☐ No IF SO, WHICH EMPLOYEE:
Page 4 of 10
Early Head Start Enrollment Application
FAMILY INCOME
INCOME SOURCES TANF (CASH ASSISTANCE) STATUS: ☐Yes ☐No ☐Formerly on TANF/Not now MONTHLY AMOUNT OF
TANF? $
DO YOU OR A FAMILY MEMBER LIVING WITH AND SUPPORTED BY YOU RECEIVE SUPPLEMENTAL SECURITY INCOME BENEFITS (SSI)? ☐Yes ☐ No
IF SO, WHO? MONTHLY AMOUNT OF SSI? $
DO YOU OR A FAMILY MEMBER
RECEIVE CHILD SUPPORT? ☐Yes
☐No
IS CHILD SUPPORT
COURT ORDERED? ☐Yes ☐No ☐ N/A MONTHLY AMOUNT OF CHILD
SUPPORT? $
DO YOU OR A FAMILY MEMBER
RECEIVE A PENSION? ☐Yes
☐No
IF YES, SPECIFY:
MONTHLY AMOUNT? $
DO YOU HAVE ANY OTHER SOURCE OF
INCOME? ☐Yes
☐No
IF YES, SPECIFY:
MONTHLY AMOUNT? $
EMPLOYMENT INFORMATION/INCOME INFORMATION FOR THE PAST 12 MONTHS
1.
SELECT THE WORKING ADULT FROM THE DROP-DOWN
IF WORKING ADULT IS NOT THE PRIMARY OR
SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:
EMPLOYER: OCCUPATION:
HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment
WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month
2.
SELECT THE WORKING ADULT FROM THE DROP-DOWN
IF WORKING ADULT IS NOT THE PRIMARY OR
SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:
EMPLOYER: OCCUPATION:
HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment
WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month
3.
SELECT THE WORKING ADULT FROM THE DROP-DOWN
IF WORKING ADULT IS NOT THE PRIMARY OR
SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:
EMPLOYER: OCCUPATION:
HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment
WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month
4.
SELECT THE WORKING ADULT FROM THE DROP-DOWN
IF WORKING ADULT IS NOT THE PRIMARY OR
SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:
EMPLOYER: OCCUPATION:
HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment
WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month
5.
SELECT THE WORKING ADULT FROM THE DROP-DOWN
IF WORKING ADULT IS NOT THE PRIMARY OR
SECONDARY ADULT, PLEASE GIVE FIRST AND LAST NAME:
EMPLOYER: OCCUPATION:
HIRE DATE: ☐Full-time ☐Part-time ☐Current Employment ☐Previous Employment
WEEKLY HOURS WORKED: GROSS INCOME: $ ☐Weekly ☐Every 2 weeks ☐Monthly ☐Twice per month
Number of people living in the house: Number of people supported by the parent or guardian’s income:
Page 5 of 10
Early Head Start Enrollment Application
FAMILY CIRCUMSTANCES
Please answer each item with “Yes” or “No.” Documentation must be provided for any item answered “Yes.”
Does the child have medical issues (prematurity, failure to thrive, spina bifida)? ☐ Yes ☐ No
Does the child have a diagnosed condition by a professional? ☐ Yes ☐ No
DO ANY OF THE FOLLOWING APPLY TO YOUR FAMILY? (Please refer to page 8 for items requiring documentation)?
1. Homeless ☐ Yes ☐ No
2. Incarcerated Parents ☐ Yes ☐ No
3. SSI/TANF Recipients ☐ Yes ☐ No
4. Families with prior DCF History ☐ Yes ☐ No
5. Disaster Evacuee ☐ Yes ☐ No
6. Impacted by Gun Violence ☐ Yes ☐ No
7. Substance Abuse ☐ Yes ☐ No
8. DCF Referral and Court Order ☐ Yes ☐ No
9. Domestic Violence ☐ Yes ☐ No
10. Parent is Enrolled in School ☐ Yes ☐ No
11. Working Parent ☐ Yes ☐ No
12. Teen Parent ☐ Yes ☐ No
13. Sibling of Returning Student ☐ Yes ☐ No
14. Migrant Seasonal Farm Worker ☐ Yes ☐ No
15. Public Housing Resident ☐ Yes ☐ No
16. Infant Mortality ☐ Yes ☐ No
17. Pregnant Woman ☐ Yes ☐ No
18. Postpartum Depression ☐ Yes ☐ No
19. Enrolled in Current Center ☐ Yes ☐ No
Page 6 of 10
Early Head Start Enrollment Application
FAMILY EMERGENCY CONTACTS
CHILD’S NAME: CHILD’S DATE OF BIRTH PARENT/GUARDIAN’S NAME:
EMERGENCY CONTACTS: Child will be released only to the custodial parent or legal guardian and the people listed below. The people below will also be contacted and are authorized to remove the child from the facility in case of illness, accident, or emergency. This form must be updated as changes occur.
1.
NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent
☐ Other
ADDRESS: CITY: STATE: ZIP CODE:
PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:
☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work
2.
NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent
☐ Other
ADDRESS: CITY: STATE: ZIP CODE:
PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:
☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work
3.
NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent
☐ Other
ADDRESS: CITY: STATE: ZIP CODE:
PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:
☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work
4.
NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent
☐ Other
ADDRESS: CITY: STATE: ZIP CODE:
PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:
☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work
5.
NAME: RELATIONSHIP: ☐ Sibling ☐ Aunt/Uncle ☐ Grandparent
☐ Other
ADDRESS: CITY: STATE: ZIP CODE:
PHONE NUMBER: TYPE: ALTERNATE NUMBER: TYPE:
☐ Cell ☐ Home ☐ Work ☐ Cell ☐ Home ☐ Work
Page 7 of 10
Early Head Start Enrollment Application
ADDITIONAL FAMILY MEMBERS
4.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
5.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
6.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
7.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
8.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
9.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
10.
FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX:
NICKNAME: DATE OF BIRTH: GENDER: LAST 4 NUMBERS OF THE SSN
☐ Male ☐ Female
RELATIONSHIP:
☐ Sibling ☐ Aunt/Uncle ☐ Grandparent ☐ Other
Page 8 of 10
Early Head Start Enrollment Application
REGISTRATION REQUIREMENTS
All Yellow Items Are Required Check off documents being submitted (to be checked off by parent)
Person receiving application, please write date received
Proof of Age: ☐ Birth Certificate
☐ Passport
☐ Notarized Affidavit of Age
☐ Immunization Record
Proof of parent’s/legal guardian gross income for the past 12 months or the last calendar year
Important: Submit document(s) as proof of income for each person contributing to the family income or for multiple jobs.
☐ Signed Income Form Tax 1040 with correct household size
☐ W-2 forms
☐ Pay stubs (proof for the last 6 weeks)
☐ Unemployment Compensation
☐ Written statements from employers (letterhead)
☐ Social Security Supplemental Income (SSI) printouts
☐ Public Assistance (TANF) Printouts
☐ Child Support
☐ Notarized Income Statement
Proof of Parent’s Identification ☐ Driver’s license/Passport/ID from Homeless Shelter
☐ State issued picture I.D.
☐ Employer issued I.D.
☐ Military ID
Proof of Dade County Residency ☐ Driver’s license with address listed
☐ State issued picture I.D. with address listed
☐ Utility Bills/Statements (lights, phone, cable, etc.)
☐ Lease Rental /Mortgage Agreement
☐ Employer Record (Paystub)
Submit proof only if applicable Support Documents Date Received
School Readiness Enrollment ☐ Non-Transferable Child Care Certificate for School Readiness
School Readiness Waitlist ☐ Waitlist Confirmation Email
Disability (applicant child) ☐ Individualized Family Support Plan (IFSP)
Suspected Disability (applicant child) ☐ Doctor’s/Therapist’s Statement outlining concerns
Substance Abuse ☐ Written Statement from Treatment Program
Domestic Violence ☐ Written Statement from Domestic Violence Agency/Court
☐ Referral from Partnering Agency if Undocumented Domestic Violence
DCF Referred and Court Order ☐ DCF Referral/Court Order
Prior DCF History ☐ DCF or Court Order document of prior case
Student (Parent) ☐ Current transcripts/schedule
Pregnant Woman ☐ Written Medical Documentation (current)
Public Housing Resident ☐ MDPHA Written Rental/Lease Agreement
Incarcerated Parent ☐ Sentencing Order/Signed Affidavit or Letter from Prison
Enrolled in Current Center ☐ Statement from Owner of Child Care Center
Disaster Evacuee ☐ Notarized declaration letter from parent/ FEMA Documentation
Impacted by Gun Violence ☐ Police Report (if available)
Infant Mortality ☐ Death Certificate (if available)
Postpartum Depression ☐ Doctor’s letter with diagnosis (if available)
Homeless ☐ Written Statement from Homeless Facility (if available)
Foster Care/Legal Custody ☐ Documentation from Foster Care Agency/ Court Award
Guardianship/Legal Custody ☐ Documentation from Court System/ Court Award
Referred by Partnering Agency ☐ Referral from Partnering Organization
Page 9 of 10
Early Head Start Enrollment Application
Acknowledgement
Important:
Please read carefully before signing.
• I certify that the information provided in this application package and all
supporting documentation are accurate and truthful.
• I certify that all sources of income supporting the household have been reported
and corresponding proof has been submitted according to program
requirements.
• I understand that providing false information or income omissions to qualify for
the program may be grounds for rejection of this application or termination from
the program.
• I will notify the program immediately if there are any changes to my contact
information, income, or family circumstances.
• I understand incomplete applications will not be accepted.
Signature Instructions (Important) • Printed Applications:
If you completed this application manually, please sign with a pen on the Parent/Guardian Signature (eSignature) line below.
• Electronic Applications:
If you completed this application on the computer and are submitting via email, please type your first and last name after the “/s/” on the Parent/Guardian Signature (eSignature) line below. By typing your first and last name after “/s/”, you understand that it is an electronic signature that has the same legal effect as a manual signature.
Parent/Guardian Signature (eSignature): /s/ _____
Date:
Page 10 of 10
Early Head Start Enrollment Application
For Eligibility and EHS Use only:
Eligibility Verification
Child’s Name: DOB:
This child is eligible to participate in the program: ☐ Yes ☐ No
Family Size: (Supported by the income of the parent(s) or legal guardian)
Total Family Income:
Check the applicable category of eligibility for this child ☐ Homeless
☐ Foster Care
☐ Public Assistance
Income (check box that applies): ☐ Below federal poverty guidelines
☐ Between 100-130% of federal poverty guidelines (no more than 35% of enrolled children may fall into this category)
Over-Income: ☐ Counted as part of 10% maximum for non-AI/AN programs
☐ Counted as part of the 49% maximum for non-AI/AN programs
What type of documentation was used to determine eligibility? ☐ Income Tax Form 1040 ☐ ELC Verification of Income ☐ EHS Declaration of Income
☐ W-2 ☐ ELC Work Calendar ☐ Child Support
☐ TANF Documentation ☐ Employer Letter ☐ 1099 – Misc.
☐ Pay stubs or pay envelopes ☐ Foster care – Court Order ☐ Other
☐ Unemployment Benefits ☐ SSI Documentation If Other, please explain:
Relevant Time Period for Income: ☐ Current Year ☐ Previous 12 months
I have examined the income documents checked off above and verify that the child is income and age eligible to participate in the program. Disciplinary action will be taken against staff that intentionally violate federal and program eligibility determination regulations by enrolling families that are not eligible to receive Early Head Start services. Signature of Staff Entering Applications: (Electronic Signature Acceptable)
Date of eligibility verification:
Staff Name (Print or Type):
Staff Title:
Signature of Secondary: (Electronic Signature Acceptable)
Date of eligibility verification:
Secondary Staff Name (Print or Type):
Secondary Staff Title:
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .08 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.