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About Us
Events
Programs
Head Start / EHS
About HS & EHS
HS & EHS Forms
Services
Ojibwe L&C
Education
Family & Community Partnership
Health, Nutrition & Safety
Special Needs
Monitoring & Reporting
Child Care Services
About CCS
Maajiigin Family Center
Outdoor Learning
Classrooms
Licensing & Support
Parent and Family Services
Ojibwemowin
Resources
Outreach
MNTRECC
Planning & Advisory
Newsletters
Resource Links
Provider Grants
Curriculum & Language
SNAP-Ed
Language
Employment
Contact Us
Application
admin
2021-03-25T19:23:55+00:00
HS & EHS Enrollment Application
Child Information
Child #1 Full Name
*
Applying For
HS
EHS
Before and After
Child Enrolled
No
Yes
If yes, which tribe?
Date of birth
January
February
March
April
May
June
July
August
September
November
December
Sex
M
F
Primary Language
Ethnicity (Hispanic)
Yes
No
Race
Option
Black
Native Hawaiian/Pacific Islander
Asian
White
Native American
Other
Child #2 Full Name
Applying For
HS
EHS
Before and After
Child Enrolled
No
Yes
If yes, which tribe?
Date of birth
January
February
March
April
May
June
July
August
September
November
December
Sex
M
F
Primary Language
Ethnicity (Hispanic)
Yes
No
Race
Option
Black
Native Hawaiian/Pacific Islander
Asian
White
Native American
Other
Child #3 Full Name
Applying For
HS
EHS
Before and After
Child Enrolled
No
Yes
If yes, which tribe?
Date of birth
January
February
March
April
May
June
July
August
September
November
December
Sex
M
F
Primary Language
Ethnicity (Hispanic)
Yes
No
Race
Option
Black
Native Hawaiian/Pacific Islander
Asian
White
Native American
Other
Primary Adult
Secondary Adult
Email Address
Living Address
Mailing Address
City
City
State
State
zip
zip
Primary Phone
Work Phone
Emergency Phone
Parental Status
Single
Two
Relationship
Natural/Adopted/Step
Grandchild
Niece/Nephew
Foster
Other
Total Number of Children
Homeless
Yes
No
Number in Household
Number in Family
Primary Language in Home
WIC
Yes
No
Do you receive Food Support?
Yes
No
Are you receiving public assistance?
Yes
No
Do you have medical/health insurance?
Yes
No
Would you like assistance in obtaining insurance?
Yes
No
Health Coverage (MA, MN Sure, Private)
Do you use IHS as your primary care? (IHS is not insurance)
Yes
No
Doctor
Dentist
Clinic
Clinic
City
City
State
State
Zip
Zip
Phone
Phone
Teen Parent (21 or under at birth of enrolling child)
Yes
No
Active in Military
Yes
No
US Military Veteran
Yes
No
Adult Family Members
Name
Provides Financial Support
Yes
No
Date of Birth
Insurance
Yes
No
Sex
M
F
Highest Grade Completed
---
High School
G. E. Diploma
Some College
College Degree
Associates Degree
Bachelor's Degree
Master's Degree
Present Employment Status
---
Full Time Work/Training
Full Time (35h/wk)
Part Time Work/Training
Retired/Disabled
Part Time (Less than 35h/wk)
Seasonal
Transitional/School
Unemployed
Name
Provides Financial Support
Yes
No
Date of Birth
Insurance
Yes
No
Sex
M
F
Highest Grade Completed
---
High School
G. E. Diploma
Some College
College Degree
Associates Degree
Bachelor's Degree
Master's Degree
Present Employment Status
---
Full Time Work/Training
Full Time (35h/wk)
Part Time Work/Training
Retired/Disabled
Part Time (Less than 35h/wk)
Seasonal
Transitional/School
Unemployed
Name
Provides Financial Support
Yes
No
Date of Birth
Insurance
Yes
No
Sex
M
F
Highest Grade Completed
---
High School
G. E. Diploma
Some College
College Degree
Associates Degree
Bachelor's Degree
Master's Degree
Present Employment Status
---
Full Time Work/Training
Full Time (35h/wk)
Part Time Work/Training
Retired/Disabled
Part Time (Less than 35h/wk)
Seasonal
Transitional/School
Unemployed
Children
Name
Date of Birth
Insurance
Yes
No
Sex
M
F
Child/Primary Relationship
Custody
Yes
No
Name
Date of Birth
Insurance
Yes
No
Sex
M
F
Child/Primary Relationship
Custody
Yes
No
Was child referred to the program?
Yes
No
If yes, by whom?
Why?
Child has disability or special need?
Yes
No
Suspected
If yes, diagnosis, date, and source
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