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The School District of Philadelphia Office of Early Childhood Education440 N. Broad Street, Philadelphia, PA 19130 215.400.4270PrekindergartenHead StartApplication[Initial Screening]Return Completed ApplicationThe School District of PhiladelphiaPrekindergarten Head Start Program440 N. Broad Street- Suite 170Philadelphia, PA 19130Please Note: Completing and submitting an application does not guarantee enrollment.In accordance with applicable Federal and State civil rights laws and regulatory requirements, you have the right to apply for services withthe School District of Philadelphia and to be referred for services at other facilities without regard to your race, color, national origin,disability, age, sex and religion. You have the right to file a complaint of discrimination if you feel you have been discriminated against onthe basis of your race, color, national origin, disability, age, sex and/or religion. Complaints of discrimination may be filed with any of thefollowing:Bureau of Equal OpportunitySoutheast Regional Office801 Market St. Suite 5034Philadelphia, PA 19107Commonwealth of PennsylvaniaHuman Relations Commissionth110 N. 8 StPhiladelphia, PA 19107Office of Civil RightsU. S. Department of Health andHuman Services Region III150 S. Independence Mall WestSuite 436, Public Ledger BuildingPhiladelphia, PA 19106

THE SCHOOL DISTRICT OF PHILADELPHIAOFFICE OF EARLY CHILDHOOD EDUCATIONEDUCATION CENTERnd440N.BROADSTREET,2FLOOR- ‐PORTALCPHILADELPHIA,PENNSYLVANIA19130- ‐1099TELEPHONE215- ‐400- ‐4270FAX215- ‐400- ‐4271Renee Queen JacksonDeputy ChiefJoy DiljohnExecutive Director, Head StartDear Parents and GuardiansThank you for your interest in pre-registering your child(ren) in the School District of Philadelphia’s Head Startprogram. Applications for the up-coming school year are accepted beginning December 15th until March 31st.Please complete the attached form, accompanied by supporting documentation to verify your income and child’s age.Completed applications will take a minimum of six (6) weeks to be processed. Entry into the Head Start program isbased on need, and applicants will be placed on a waiting list in order of need. All applicants will be notified by mailwhether their child has a space for the 2013-2014 school year or if their child will remain on the waiting list.In order for us to determine your eligibility, we need to receive copies of the following information: Application: (Completed and signed)Application for Admission of Child to School (EH-40)Proof of Child’s ageProof of current income of Parent(s)/Guardian(s) of childProof of Philadelphia ResidencyChild Custody information/documents (if applicable)An Individual Learning Plan (IEP) if your child has a disability (if applicable)Early Head Start Letter (if applicable)Child’s health insurance cardPicture ID of Parent/GuardianHealth Assessment and Dental ExamOther Family/Health/Nutrition InformationPlease see page 3, “Other Head Start Information” for more information on what documents can be used to meet theserequirements.These documents must be submitted to us before your application can be evaluated. Please submit COPIES only. Yourchild will not have the opportunity to be offered enrollment in the program nor have his/her name placed on the waitinglist if his/her application is incomplete. To ensure that your application is complete, refer to the checklist at the end ofyour application.Please submit your Head Start application and copies of all required documents by using the following methods:Mail or Bring:Drop Box Locations:The School District of PhiladelphiaPrekindergarten Head Start440 N. Broad Street, Suite 170Philadelphia, PA 19130The lobby of the Education Center Broad St. EntranceThe Entrance to the Office of Pre-K Head Start at the Education Center,1st floorThe Office of Early Childhood Education Center Suite, 2nd floorPAGE 2

The School District of PhiladelphiaADDITIONAL HEAD START INFORMATION1.2.3.4.5.6.7.8.Head Start centers are not located in every school therefore, limited spaces are available.Head Start is a FREE Prekindergarten program for children 3-5 years of age.Head Start is funded by the Federal Government and the School District of Philadelphia.Applications are reviewed using selection criteria to identify children and families with the greatestneed for services in accordance with and guidance from the Federal Head Start Performance Standardsand other regulations.Children who will be eligible for kindergarten the next school year are given priority/specialconsideration.Parents will be notified if the centers selected are filled and their children’s names will be placed onthe waiting list. Parents will also be notified if their children are not eligible for the program alongwith the reasons for ineligibility.Applications are valid only for the program year in which they are completed. If a child is age eligiblefor the next program year, parents will be notified to update all information for the new program year.We determine whether you are eligible based on your family size and yearly gross income. We use theFederal Income Poverty Guideline issued each January in the Federal Register by the Department ofHealth and Human Services as our guide.2013 Poverty Guidelines forthe 48 Contiguous States andthe District of Columbia:Persons in FamilyPoverty Guidelines12345678 11,490 15,510 19,530 23,550 27,570 31,590 35,610 39,630For families/households with more than 8 persons, add 4,020 for each additional person.Acceptable documents to process application:Proof of Child’s AgeProof of current income ofParent(s)/Guardian(s) of childProof of PhiladelphiaResidencyBirth CertificateSubmit 4 week’sworth of paystubsSelf EmploymentTax StatementUtility billHospital recordW 2- 1040 tax form(1st two pages)Current voter’sregistration cardOfficial document thatverifies date of birth.Social Securityincome letterWritten statementfrom employer orpay envelopesNotarized letter ofsupport from familymember where youresidePublic Assistanceletter or CompassReportUnemploymentverificationFoster care letterfrom agencyRental agreementShelter placementletter for homelessstudentsNote: In addition, other information (documentation) may be requested by the Social Service Coordinator, according toFederal regulations, in order to determine eligibility.PAGE 3

Primary Adult’s Last NameTheSchoolDistrictofPhiladelphiaPre- ‐KindergartenHeadStartProgramApplicationFirst NameChild’s Last NameChild’s Date of BirthFirst NameGeneral Info rmationAddressApartment #CityStateZipEmail Address:PrimaryPhone Type (HOME, CELL, WORK) Phone NumberChild’s InformationLastFirstDate of BirthGenderMiddleMFIs the child Hispanic? Yes No American Indian Asian Black/African American Multi-Racial/Bi-Racial Native Hawaiian/Pacific Islander White OtherIs English, the primary language of the child? Yes No Little Moderate ProficientIs another language spoken by child? Yes NoIf yes, list the language: Little Moderate ProficientDoes the child have a disability? Yes NoIf yes, does your child have any of the following: IEP IFSPDoes the child have health insurance? Yes NoRace (check all that apply):If yes, what type of health Insurance (Please circle): CHIP Medical AssistanceInsurance Name:PrivateInsurance Number:Doctor’s Name :Address:Phone:Dentist’s Name:Address:Phone:Household Informa tionParental Status: One Parent in the home Both Parents are in the homeTotal number of family members:Total number of children:Other Family M embers S upported by Primary Adu ltGenderAdult/ChildLast NameFirst NameF/MPAGE 4Relationship to childDate of Birth

First Parent #1 o r Legal GuardianLastFirstMiddleDate of BirthIs the primary adult Hispanic?Gender Yes NoRace (check all that apply): American Indian Asian Black/African American Multi-Racial/Bi-Racial Native Hawaiian/Pacific Islander White OtherIs English, the primary language of the primary adult? Yes No Little Moderate ProficientIs another language spoken? Yes NoIf yes, list the language: Little Moderate ProficientRelationship to the child: Natural Step parent Foster Guardian Other Specify:Lives with the family?Provides financial support to the family?*Is a Teen parent? Yes No Yes No Yes NoAdult’s highest education completed:th 9 grade or less High School Graduate 10th grade Some collegeth 11 grade Associate’s Degree 12th grade Bachelor’s Degree General Education Diploma Master’s Degree Training Certificate Doctoral DegreeEmployment Status: Full-time and Training Full-time Part-time and Training Part-time Retired or Disabled Seasonally Employed Training or School UnemployedIf unemployed, for how long?If in school/training, where?Parent #2LastFirstMiddleDate of BirthGenderIs the secondary adult Hispanic? Yes NoRace (check all that apply): American Indian Asian Black/African American Multi-Racial/Bi-Racial Native Hawaiian/Pacific Islander White OtherIs English, the primary language of the primary adult?Is another language spoken? Yes No Other Specify: Proficient Little Moderate Proficient Natural Step parent Foster GuardianLives with the family?Provides financial support to the family?Is a teen parent? Yes No Yes No Yes NoAdult’s highest education completed: 9th grade or less High School Graduateth 10 grade Some college 11th grade Associate’s Degreeth 12 grade Bachelor’s Degree General Education Diploma Master’s Degree training certificate Doctoral DegreeEmployment Status: Full-time and Training Full-time Part-time and Training Part-time Retired or Disabled Seasonally Employed Training or School UnemployedIf unemployed, for how long?If in school/training, where? Moderate Yes NoIf yes, list the language:Relationship to the child: LittlePAGE 5

Family InformationDo you receive any of the following assistance: YesCash Assistance No Yes NoAre up doubled up with family orIf yes, since when? Yes No Yes No Yes NoHave you received permanent Yeshousing in the past 12 months? NoAre you in a shelter/transitionalIf yes, since when?housing? If yes, since when? Yes NoOther, please specify:If yes, provide WIC ID?If yes, since when? Yes No Yes No Yes NoIf yes, since when?If yes, since when?Medical Assistance Yes NoFriends due to fire, flood, etc.Social Security IncomeChild Support NoIf yes, since when?Food Stamps (SNAP)Child Care Vouchers YesAre you homeless?If yes, since when?WICCurrent housing status:Does your family have other Social Concerns:[ EnglishLanguage learners, custody issues, etc.] YesIf Yes, state concern:What is frequency of pay: (How often do you get paid?)Parent 1: Weekly Bi-weekly Bi-monthly MonthlyParent 2: Weekly Bi-weekly Bi-monthly MonthlyMiscellaneous information: Are you a United States Citizen?YesIf no, how long have you lived in USA? Yes No Yes No NoIs there a sibling enrolled in Head Start?Do you have a medically fragile child?(chronic or terminal illness)Do you have any disabilities or physicalor mental health concerns? No YesDoes your child have previouspreschool experience? Yes NoDo you have a preference in school site? ( S e e S c h o o l L i s t o n P a g e 9 )If yes, which site? YesChoice 1 :Choice 2:Choice 3:Note: The preferred school site cannot be guaranteed.PAGE 6 No No

esthat:1. PTEDINTOAPRESCHOOLPROGRAM;2. cewithintheprogram.3. tionchanges4. juredwhileattendingpreschool;5. uledarrivalanddeparturetimes.I understand that this application does not guarantee enrollment in Head Start.I have enclosed the following required documents pplicationforAdmissionofChildtoSchool(EH- ‐40)Pages2- ystubs(weekly,bi- ‐weekly,monthly,etc.)stW2- ‐1040taxform(1twopages)SelfEmployment- t/Guardian Signature:Date:NoYesParent/Guardian ILLNOTBEPROCESSEDPAGE 7No