Dear Family,

Thank you for your interest in the Head Start Child Development Program. Please complete the application in full along with the following documents attached: 

• Recent proof of your family’s income (Cash Grant Action Notice or Passport to Services from Social Services, pay stubs for one whole month, Social Security payment notice, written verification from your employer or person providing for you at this time, your mostrecent W-2or Tax return).

We welcome individuals with special needs, food allergies and other medical conditions. Please note that additional follow up may be requested from agencies and/or medical providers currently working with you in order to ensure that the program meets your needs.

We use a point system that gives selection priority in certain situations, so it is important to answer each question on the application.

If you have questions about the application, need help in returning it, or would like copies made of your documents, please call us at (707) 462-2582.

After processing your application, we will send a letter about your application status. Please note your application will only be considered for the program year you are applying for. Thank you for choosing the NCO Head Start Child Development Program as part of your child's early learning experience. We look forward to meeting you.

WE WELCOME FAMILIES WITH SPECIAL NEEDS

The HSCDP does not discriminate on the basis of gender, sexual orientation, ethnic group identification, race, ancestry, national origin, religion, color, mental or physical disability, or immigration status in determining which children are served.

I certify this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand the information in this application will be held in strict confidence within the agency and is accessible to me during business hours. This information will not be released without my written consent.

RELEASE OF MEDICAL INFORMATION:
I agree to the release of medical information between Head Start Child Development Program and my child’s Medical Providers, Dental Providers, the local Health Department and the WIC program for the purposes of coordination to provide the best possible health services to my child, and to meet the requirements for documentation of such services of the Head Start Child Development Program. This permission for release of information is in effect from the date of signing this form and during the period of time I am / my child is enrolled in NCOHSCDP and is pursuant to HIPAA and California law and includes, but is not limited to, any physician, health care professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or any other covered health care provider. I understand this written consent is voluntary and subject to revocation at any time.