Head Start Application

Guidestar Child Care Center
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Child

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Gender *
Hispanic *
Race
 
English proficiency
Other language proficiency
Primary health coverage
Other coverage
Medicaid eligibility
Dental coverage
How did you hear about our EHS program
 

Birth history

Was child born
Problems at the hospital for mother or child
 

Special needs

Does child have any special needs or disability?
 
Has the disability been professionally diagnosed?
Does child have an Individualized Family Service Plan (IFSP)?
Are you involved with Help Me Grow?
Has your doctor or other medical professional referred you to Help Me Grow?

Medical history

Is child taking any medication?
 
Has child had a condition diagnosed by a physician?
 
Has child ever had surgery?
 
Has child ever been hospitalized for asthma?
 
Does child have
 

Nutrition

Is child breastfed?
 
Is child bottle fed?
Is child's height and weight good for her/his age?
 
Is child on any special diet given by a doctor?
 
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Family information

Is any family member receiving counseling?
 
Is anyone currently pregnant?
Receiving prenatal care?
 
Does anyone have any difficulty reading or writing?
 
Are you involved with Community Properties of Ohio (CPO)?
Moms2B participant?
Your house or apartment
Are you receiving PFCC?
Is at least one parent/guardian a veteran of the United States military?
Parent or guardian has insurance?

Consent to screen

Check below to consent to screenings by the Early Head Start program and to affirm the following.

I understand that one of the requirements of The Early Head Start program is for my child to receive screenings. I give permission for my child to receive the screenings listed below during the time he/she is enrolled in the program. I understand that I can revoke this permission in writing at any time. The screenings have been explained to me, and I will be informed of the results at the time the screenings take place.
Developmental screen *
Behavioral screen *
Speech screen *
Physical examination *
Dental screen *
Vision screen *
Hearing screen *

Authorization to exchange information

The Early Head Start Partnership Program will offer many services to your child and family. In order for the program to be most effective, the services listed below will be working together to meet the needs of your child, family and the requirements of the program. By authorizing information exchange you will allow the partnering agencies to share information regarding your child and family for the purpose of providing continuity of care.
 
Check below to authorize information exchange and affirm the following
 
I hereby authorize The Early Head Start Program and its partnering agencies listed below to share pertinent program information related to health, education, development, nutrition, behavioral health and social services. I understand my family’s information will be protected by state and federal laws of confidentiality.
 
Partnering Services:
The Early Head Start Program
Child’s Physician/Medical Practice listed below
Guidestar Child Care Center
 
• Children’s Hunger Alliance
• Maryland Public Health Department
• Community Properties
• Directions for Youth and Families
• Montgomery County Board of Developmental Disabilities
• Montgomery County Department of Job & Family Services
• Montgomery County Family & Children First/Help Me Grow
• Moms2B
• Nationwide Children’s Hospital
• New Directions Career Center
• St. Vincent Family Center
 
I understand this exchange of information is valid for the duration my child is enrolled in the Early Head Start Program. I understand the authorization is voluntary. I may revoke this consent at any time with written notice. If I revoke the consent, it will end all sharing of information from the date written notice is received but will not change the information that has been shared previously. This exchange of information has been explained to me by staff member:
Information exchange authorization *

Office use section - will not be visible to parents

Staff attestation for consent to screen: I have discussed the consent to screen information with the parent/guardian listed above. I believe that he/she fully understands this information and is giving informed and willing consent.
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Staff attestation for exchange of information: I have discussed this exchange of information with the parent/guardian listed above. I believe the parent/guardian fully understands this release and is giving informed and willing consent.
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Primary adult

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Gender *
Hispanic *
Race
 
English proficiency
Other language proficiency
Highest grade completed
Employment status
Child's relationship
 
Custody
Check all that apply
If teen, subsidized?

Secondary or other adult

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Gender
Hispanic
Race
 
English proficiency
Other language proficiency
Highest grade completed
Employment status
Child's relationship
 
Custody
Check all that apply
If teen, subsidized?

Additional child (non-applicant)

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Gender
Hispanic
Race
 
English proficiency
Other language proficiency

Additional child (non-applicant)

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Gender
Hispanic
Race
 
English proficiency
Other language proficiency

Additional child (non-applicant)

 +
Gender
Hispanic
Race
 
English proficiency
Other language proficiency

Additional child (non-applicant)

 +
Gender
Hispanic
Race
 
English proficiency
Other language proficiency

Family information, income & contacts

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Same as living *
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Text messages *
Text messages
Text messages
Parental status *
Homeless family *
Active duty military *
Referred by child welfare agency *
Receiving SNAP *
Receiving WIC *

Location preference

Family income - this section will not be visible to parents, only to administrative staff

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TANF status
SSI
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Parent or guardian signature

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