NCO Head Start Child Development Program Application

NCO Head Start Child Development Program Application - Prenatal

Please complete a separate application for each person.
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.

HEALTH HISTORY AND MEDICAL AUTHORIZATION
Applicant's Name:

First NameLast Name
Applicant's Date of Birth:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Cell Phone:
Please enter a valid phone number.
Message Phone:
Please enter a valid phone number.
Do you have a prenatal care provider?*

YesNo
If yes, name of prenatal care provider:
Do you have a dental provider?*

YesNo
Have you received prenatal care?*

YesNo
If you are receiving prenatal care, in which month did you begin care?
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.
Today's Date:*

MonthDayYear
Date
Applicant Signature*

Clear

If you have any attachments to add, please do so here:
Files allowed include: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif.

Cancelof
Should be Empty:

	Child's Name	Date of Birth	Sex	Relation to Applicant
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NCO Head Start Child Development Program Application - Prenatal

HEALTH HISTORY AND MEDICAL AUTHORIZATION

HEALTH ASSESSMENT

If you have any attachments to add, please do so here: