Redding Rancheria Head Start Pre-Application Form

 

Child's Name (Last, First, Middle):
Date of Birth:
Interested in
(check all that apply):
Head Start
Subsidized Child Care
Private Pay Child Care

For school age children, school attending:
Grade:

 

Child's Race/Ethnicity:
Tribal Affiliation:
White (non-Hispanic)
Black (non-Hispanic)
Hispanic
Other
Has the child been diagnosed with or is the child suspected to have any special needs?
Is the child receiving Child Protective Services?
Address where the child lives:
Requesting Transportation?

 

Family Information

Father's Name (Last, First, Middle):
Home Phone:
Message Phone:
Work Phone:
Father's Workplace:
Mother's Name (Last, First, Middle):
Home Phone:
Message Phone:
Work Phone:
Mother's Workplace:
Family Type:
Single Parent Family
Foster Family
Other
Number of adults (18 years and older) in the household:
Number of children (less than 18 years old) in the household:
Total Number of people in the household:
Who is your current child care provider?

 

Income (please enter all sources of monthly income and state amount):

Mother's Work:
Father's Work:
Cal Works:
Child Support:
Medical/Medicare:
Social Security:
Unemployment:
Public Assistance (TANF):
Foster Care/Adoption:
Other/Subsidies:
Food Stamps:
WIC:
Public Housing:
Child Care Assistance:
Energy Assistance:
Total monthly income (Gross)

 

If parent(s) are attending schooling, please state which school and current schedule:

 

Acknowledgments

Please be advised the information in this document does not automatically qualify your child for enrollment in the Redding Rancheria Head Start & Child Care Program. This Pre-Application Form is for evaluation purposes only. When a vacancy occurs, you will be asked to provide documentation and complete the entire application packet to continue your enrollment process.

I certify the information provided is accurate and truthful to the best of my knowledge. I understand enrollment is not based on a first come first served basis, but is based on the highest need. I understand that I will be required to provide further documentation prior to enrollment to confirm eligibility.

*Please call the center at 225-8925 after submitting form to confirm receipt.

 

Redding Rancheria 2000 Redding Rancheria Road, Redding, CA 96001
Tribal Administration Office: (530) 225-8979
Tribal Administration Fax: (530) 241-1879
Toll Free 1 800-479-8979