Doña Ana County Head Start/ Early Head Start A Child Development Program

2540 El Paseo, Suite B Las Cruces, NM 88001

Since 1965, the Federal Head Start Program has pioneered a tremendously successful approach to how children learn, grow and develop.

Mission Statement The mission of Dona Ana County Head Start/ Early Head Start is to provide a quality comprehensive preschool program that is in a

dedicated partnership with parents and the community.

Overall Goal To bring about a greater degree of social competence in children of low-income families

Statement of Philosophy Doña Ana County Head Start/ Early Head Start believes:

Parents are a child’s primary educator and as such, we will have greater success in meeting our program goals by actively supporting and involving a child's family in his/her education.

In order for a child to learn effectively, he/she must have a strong positive self-concept, which is developed by immersing a child in positive social environments while engaging in learning experiences.

A preschool program must address the needs of the total child. This includes medical, dental and nutritional needs as well as social, cultural, emotional and intellectual needs.

Children learn actively, using all of their senses to interact with their environment.

Children learn best when they are provided experiences that are:

developmentally appropriate

individually appropriate (correct for that child’s uniqueness)

culturally appropriate

Applicant Information (Print all information)

Please use a pen to fill out the application. Selection for enrollment will be based on: income, age, geographic location, employment/educational needs, special need of a child and family needs. ATTACH THE FOLLOWING DOCUMENTS TO THIS APPLICATION:

⃞ Verification of age. (Birth certificate, baptismal certificate, passport or hospital record).

⃞ Proof of income that shows total family income. (2015 income tax return form, 3 or more pay stubs, written statement from

employer, TANF, scholarships, and financial aid).

Incomplete application will not be considered for enrollment

AGE ELIGIBILITY OF CHILDREN Priority will be given to children who are 4 years of age prior to September 1.

INCOME ELIGIBILITY

To qualify, the family’s income must be below the 2016 income guidelines

Family members / Income

For more than 8 members, add $4,160 for each additional member.

FAMILIES WITH SPECIAL NEEDS CHILDREN ARE ENCOURAGED TO APPLY

Application and enrollment are provided regardless of race, sex, creed, color, national origin, or developmental delay/disability

(1) $11,880 (5) $28,440

(2) $16,020 (6) $32,580

(3) $20,160 (7) $36,730

(4) $24,300 (8) $40,890

Doña Ana County Head Start/ Early Head Start

Community Survey 2016-2017

These questions are designed to collect information about strengths and needs in Doña Ana County and to improve services.

Please circle your response. Thank you.

1. Are you currently employed? Yes No If yes: Full-time Part-time (less than 20 hrs. per week)

2. Are you a Student? Yes No If yes, where are you attending? High School Trade School College Are you pursuing? Circle those that apply:

Diploma ESL/GED Technical Associate’s Degree Bachelor’s Degree Master’s Other 3. Highest level of Education: 6 or below 7 8 9 10 11 12 13 14 15

16 17 18 19+ GED

4. Are you currently participating in a Job Training Program? Yes No If yes, what type?_______________________________________ 5. Based on your work or school schedule do you need child care? Yes No

If yes do you need: 1/2 Day Full Day Center Based Home Based

6. Are you or your spouse pregnant? Yes No If yes, are you or your spouse receiving prenatal care? Yes No If no, did you or your spouse receive prenatal care in the past? Yes No If you are pregnant, would you be interested in Expectant Mom Program? Yes No 7. Which of the following do you use for child care in your community?

Licensed childcare home Relative Child care center Bringing a baby sitter into your home 8. Would you be interested in a parenting and education program taught in your home to you and your child? Yes No 9. How do you get around town? Own car Friends/Family car Bus Other None 10. Who is the head of the household in your family? Single Female Single Male Two Parents Other 11. How many members of your immediate family reside in your home? __________ 12. Please circle the ages of children in your home that are five (5) years of age and under:

Under 6 months Between 6mos - 12mos Between 12mos - 18mo Between 18mos - 2 yrs.

Between 2 yrs. - 3 yrs. Between 3 yrs. - 4 yrs. Between 4 yrs. - 5 yrs. N/A 13. Do you have a child with a diagnosed delay / disability? Yes No If yes, how old? _____

What services are you receiving? Speech Physical Occupational Behavioral Other:____________________

14. Where do you get your income? Circle all that apply:

TANF/Cash Assistance Unemployment Compensation SSI (Supplemental Security Income)

Veteran’s Benefits Social Security Student Loans

Work Work Study Other Sources 15. Please circle the range of your family’s yearly income:

0 – 11,880 16,021 – 20,160 24,301 – 28,440 32,581 – 36,730 40,891 – over

11,881 – 16,020 20,161 – 24,300 28,441 – 32,580 36,731 – 40,890 16. Please circle all services that you are currently receiving:

Food Assistance Subsidized Housing Head Start Child Care

Medicaid State Funded Daycare (child care subsidies) WIC (Women, Infants and Children)

Healthy Start Early Head Start Other (please list): ______________________________

17. What is your racial or ethnic group? Anglo Black Hispanic Native American Other (Please specify)_________ 18. What is your primary language? Spanish English Other (Please specify)__________ 19. Do you or your family members suffer from Diabetes? Y N Hypertension? Y N Mental Health Issues? Y N

Asthma? Y N STI (STD)? Y N Dental Issues? Y N Overweight/Underweight? Y N

20. What city do you live in? _____________________________________________________________________________________________ 21. What is the greatest obstacle in securing infant - toddler - preschool child care services in your community? Please explain:

_____________________________________________________________________________________________________________________

Questions do not reflect services that any one program offers.

Applicant & Family Member Information

Applicant (Child’s Information)

First Middle Last Birthdate Gender (Print name below as shown on birth certificate)

Male

Female

Race Ethnicity English Proficiency Other Language Spoken Other Language Proficiency

Asian Hawaiian/Pacific Islander

Black Multi-Racial

White

American Indian/Alaska Native

Other

Anglo

Black

Hispanic

Other______________

None

Little

Moderate

Proficient

Spanish

Other___________

None

Little

Moderate

Proficient

Primary Health Coverage Other Health Coverage Medicaid Eligibility Doctor/Clinic Dentist/Clinic

Medicaid

Private Insurance

No Insurance

Yes

No

Not Eligible Potentially Eligible

Name_______________________

Phone #_____________________

Name_______________________

Phone #_____________________

Does this child have a diagnosed delay/disability? Yes No Who made the diagnosis?__________________________________

If yes, what is the delay/disability?_____________________________________

Receiving services from: TRESCO MECA DD-Pre Apprendamos

Other:____________________________________________________

Is this child in the process of being evaluated for a delay/disability? Yes No If yes what is the condition?___________________________________ Who is providing this service?

Adult 1

First Middle Last Suffix Birthdate Gender

Male Female

Race

Ethnicity

English Proficiency

Other Language

Other Lang. Proficiency

Asian Hawaiian/Pacific Islander Black Multi-Racial White American Indian/Alaska Native Other ________________________

Anglo

Black

Hispanic

Other______________

None

Little

Moderate

Proficient

Spanish

Other

___________

None

Little

Moderate

Proficient

Employment Status

Relationship

Custody

Highest Grade Completed

Check all that apply

Are you

Full Time

Part Time

Unemployed

Retired

Disabled

Natural/Adopted/Step

Grandchild

Niece/Nephew

Foster

Other

___________________

Yes

No

Joint

9th or Less 10th 11th

12th GED

Lives with family

Provides financial

In public housing / HUD

Adult 2

First Middle Last Suffix Birthdate Gender

Male Female

Race

Ethnicity

English Proficiency

Other Language

Other Lang. Proficiency

Asian Hawaiian/Pacific Islander Black Multi-Racial White American Indian/Alaska Native Other ________________________

Anglo

Black

Hispanic

Other______________

None

Little

Moderate

Proficient

Spanish

Other

__________

None

Little

Moderate

Proficient

Employment Status

Relationship

Custody

Highest Grade Completed

Check all that apply

Are you

Full Time

Part Time

Unemployed

Retired

Disabled

Natural/Adopted/Step

Grandchild

Niece/Nephew

Foster

Other

___________________

Yes

No

Joint

9th or Less 10th 11th

12th GED

Lives with family

Provides financial

In public housing / HUD

High School College/ Training College or Advanced Training

AA BA MA

support

Incarcerated

Homeless *Homeless is defined as loss of residence, living in a shelter, motel, car, camper, abandoned building, or train station.

Doña Ana County Head Start/ Early Head Start

High School College/ Training College or Advanced Training

AA BA MA

support

Incarcerated

Homeless *Homeless is defined as loss of residence, living in a shelter, motel, car, camper, abandoned building, or train station.

Employer Part time Full time

Name_______________________

Telephone #__________________

Student? Yes No

Part time Full time

Where?______________________

Employer Part time Full time

Name_______________________

Telephone #__________________

Student? Yes No

Part time Full time

Where?______________________

Family Information

Living Address Address Line 2 City State Zip

Mailing Address (if different) Address Line 2 City State Zip

E-Mail Address

Phone Numbers Type (check one) Name and relation (example Mom, Dad, Grandparent)

1.( ) Cell Home Work Message Other

2.( ) Cell Home Work Message Other

3.( ) Cell Home Work Message Other

Household Information

Total number in child’s family __

Total number in household __

Number of children___

Ages 0-3___

Ages 3-5___

One Parent

Two Parents

Primary language at home:

Family Income – Does your family receive any of the following?

TANF Yes No SNAP Yes No

Child Support: Yes No SSI Yes No

Active Military Family: Yes No

WIC Yes No Scholarships and/or

Financial Aid Yes No

Family Income Sources: (Include all the income in your family) Family Member Income Source Amount How often do you get paid?

Additional Family Concerns:

Choose the center closest to where you live and the session preferred:

All centers operate Monday – Thursday. AM session 8:00 - 11:30 & PM session 12:30 - 4:00.

Anthony Centers, 609 Church St. Anthony, NM 575-882-5242, 882-5282, 882-5244

AM PM Either

Berino Center, 455 Shrode Rd, Portable #126. Anthony, NM 882-2010

AM PM Either

Vado Center, 325 Holguín Rd. Vado, NM 575-233-5367, 233-2401

AM PM Either

Lester Center, 2220 Lester St. Las Cruces, NM 575-527-9013, 527-8695

AM PM Either

NMSU Center, Children’s Village – Sam Steel & Williams A-800, Las Cruces, NM 575-646-5435, 646-2889 (must meet additional criteria)

FULL DAY 7:45 – 4:00

Compañeros Center, Children’s Village – Sam Steel & Williams A-100, Las Cruces, NM 575-646-4708, 646-5435

AM PM Either

Anthony Early Head Start:

Early Head Start – Center Based (Monday-Friday Year Round) FULL DAY 8:00 - 2:30

Home Based Head Start (Year Round) Home Based

Fraud warning: employees, families and participants who intentionally commit fraud on income information may suffer legal consequences of arrest, fines, expulsions, incarceration, etc. These charges might be federal, local, state and civil suits. Agency confidentiality policies and procedures apply.

Parent/Guardian Signature_____________________________________________________ Date_______________

DO NOT WRITE IN THIS BOX. AGENCY USE ONLY.

Documents Submitted

Verification of Age Yes No Proof of Income Yes No

Verifying Staff Member: Date: