Early Childhood Enrollment Application
School Readiness / ECFE
ISD 93 Carlton Schools • 218-384-4225
Community Education/Early Education Program
• 218-384-4225 x216
Thank you for your interest in our Early Childhood Programs.
Please remember, in completing this application, you are applying for all the above programs.
Completing your application does not necessarily mean you have been accepted into any of these programs.
Please complete and return the following items:
Steps
Name of Document to be Completed
1.
Tennessen Warning
2.
Application for Enrollment
3.
Income Verification
Action Required
Read carefully, sign, date & return.
a) □ School Readiness Information and Income Eligibility Forms
b) □ Free & Reduced Lunch Application
4.
5.
Print clearly, completely fill-in, use
legal names, sign, date & return.
Return copies of all income sources
from each Parent providing financial
support for applicant.
Immunization Record for each applicant
Enrollment Class
Class Choice
Circle One:
Bridges
Transitions
Circle One: AM
PM
Thank you for mailing or delivering your fully completed application to one of the addresses below:
Megan McLain
Early Childhood Coordinator
[email protected].
us
218-384-4225
x216
Serving residents
of Carlton Early
Childhood Region
Carlton Early Childhood
530 Stine Dr. PO Box 620
Carlton, MN 55718
After your application is processed, we will contact you. Thank you for applying.
Early Childhood Application Form 2013-2014
Revised 03/27/2013
Tennessen Warning
Your Privacy Rights
This sheet tells you about your rights under the Minnesota Government Data Practices Act (“the Act”). This Act protects your privacy, but also
lets us give information about you to others if a law requires it AND we tell you before we do it. The information below tells why and when we
will ask for and give information about you. Under the Act, information about individuals is divided into four categories.
What kind of information do we collect?


Public Information: Information about you that is available to anyone.
Private Data: Information about you that can be shared only if you give us your permission or if a law allows or requires us to share the
information.

Confidential Information: Information about you that cannot be shared about you.

Summary Information: Information about you that does NOT identify you personally, which may be shared with others, generally for
reporting purposes.
Generally, we only ask for two types of information from you, public and private information. We use summary information for reports but it
does not identify you or anyone else by name or other identifying information.
Why do we ask you for this information?
We ask this information so we can:

Enroll your child in an Early Childhood Education Program.

Tell you apart from other persons with the same or similar name.

Decide if you can receive services from us, and what or how much you can receive.

Help you obtain financial or social services from other agencies or companies.

Make reports, do research, audits and evaluate our programs.

Collect money from the government for help we give you.
Do you have to answer the questions we ask? What will happen if you do not answer the questions we ask?
Generally, you do not have to give us information. However, if you do not provide us the information, we may not be able to determine whether
we can help you, or get help for you from other agencies.
Who else may see this information?
A third-party entity will evaluate the effectiveness of the ECE Scholarships program for the Minnesota Department of Education. That entity is
bound by Minnesota’s data practices and privacy laws and may not share your data with any other private entities but will share its evaluation
with the Minnesota Department of Education. We may also give the data you’ve provided to the Legislative Auditor, the Minnesota Department
of Human Services and any law enforcement agency or other agency with the legal authority to access the information, and anyone authorized by
a court order.
How else may this information be used?
We can use or release this information only as stated in this notice unless you give us your written permission to release the information for
another purpose or to release it to another individual or entity. The information may also be used for another purpose should the United States
Congress or the Minnesota Legislature pass a law allowing or requiring us to release the information or to use it for another purpose.
You have the right to copies of information we have about you.





You may ask if we have any information about you.
If we have information about you, you may ask for copies.
You may give other people permission to see and have copies of private data about you.
If you do not understand the information, you may ask to have it explained to you.
You may ask for and receive a copy of the agency’s Data practices policy.
How long will my data be kept?
Your data will be maintained for up to nine years.
How do you appeal if you think information is not accurate or complete?
Call Megan McLain at the Early Education Office at 218-384-4225 x216. Your objection may also be in writing and sent to PO Box 620 Carlton,
MN 55718. You must tell us why the information is not accurate or complete. You may send your own explanation of the facts you disagree with.
Your explanation will be attached any time that information is shared with another agency. For more information on how to do this, please call
the Invest Early Project office.
If you have any questions about the information on this form, please call the Early Childhood Education Program listed above.
Student Applicant Last Name
Early Childhood Application Form 2013-2014
Student Applicant First Name
Student Middle Name
Revised 03/27/2013
Parent / Guardian Signature
Date
Early Childhood • Enrollment Application
FC Homeless MFIP SSI
Date App Rec’d________ Age by Sept 1 _____yrs _____mo
Birth-2
IRScore___________ RFScore___________
← ← Office Use only → →
Annual Gross Income Verified
by_____________ Date_________
ECFE AM ECFE PM  Transitions  Bridges Other____________
STUDENT
Student Applicant Last Name
APPLICANT
INFORMATION
Middle Name
Student Applicant First Name
□Male
□Female
Student Street Address
P.O. Box
□Jr
□Sr □___
Student Race
Suffix
□ White
□ Black
□American Indian/Alaskan
□Asian
□ Hispanic
□Hawaiian/Pacific Islander
Mother’s First Name
City
State
County
Zip Code
MN
Last 4 Digits of
Social Security #
Student Date of Birth
Mom/Guardian
Home/Cell #
Additional Contact Person Name
Is Student a
US Citizen?
Student has a
Disability?
□Yes
□ No
□Yes
□ No
Mom/Guardian
Work #
Phone Number
Student Language
Student Health Insurance Type
1st Language - English Other________
□MA-IM Care/MN Care □HMO
2nd Language - Other________ English
□Medicare □Private □None
Dad/Guardian
Home/Cell #
Dad/Guardian
Work #
Relationship to Student Applicant
Student Applicant Concerns (please place an “x” by ALL concerns)
Premature/Low Birth Weight High Risk Pregnancy Birth Defects/Chronic Illness Medical Speech/Language Behavior
Separation Anxiety Child with no Group Experience Development Concerns Other_________________________________________
HEAD
OF
HOF Last Name
FAMILY
INFORMATION
□Male
□Female
HOF Relationship to Student Applicant
□Mom/Guardian □Dad/Guardian
□Foster Parent □Other_____________
HOF Date of Birth
Last 4 Digits of
Social Security #
HOF Average Weekly Work Hrs
HOF Marital Status
□Single □Married □Separated
□Widowed □Divorced □Living
Together □Never Married
US
Citizen?
Disability?
□ Yes
□ No
□ Yes
□ No
(HOF)
Middle Name
HOF First Name
□Jr
□Sr □___
HOF Race
□ White
□ Black
□American Indian/Alaskan
□Asian
□ Hispanic
□Hawaiian/Pacific Islander
Suffix
Mother’s First Name
HOF Vet
HOF Housing Type
HOF Family Type
□Own □Rent □Homeless
□Single Person □Single Parent/Female □Single
□Shelter □Living with
Parent/Male □Two Parent Household □Foster
□Yes □No
Extended Family
□Grandparent/Child □Non-Custodial Care Giver
HOF Highest Level of Education
HOF Health Insurance Type
If less than a high school
Trade school or some college
□MA-IM Care/MN Care
diploma. Highest grade
Associate degree
□HMO □Medicare
completed ____________
Bachelor degree
□Private □None
High school/GED
Graduate or professional degree
Status
Does Family Receive CCAP Funds?
HOF Language
1st Language - English Other_______________
2nd Language - Other_______________ English
HOF Email Address
(Child Care Assistance Program
thru Itasca Co)
□Yes
□ No
Family Concerns (please place an “x” by ALL concerns)
English is not primary language Medical/Health Issues Living with extended family Adult Disability History of Chemical Abuse
Recent Divorce/Loss Homeless/Transitional Transportation Unemployment Teen Parent Parent absent for extended period
ADDITIONAL
Additional Family Last Name
FAMILY
MEMBERS
□Male
□Female
Relationship to Head of Family (HOF)
□Spouse □Daughter □Son
□Foster Child □Other_________
Date of Birth
Early Childhood Application Form 2013-2014
Marital Status
□Single □Married
□Separated □Widowed
□Divorced □Living
Together □Never Married
Last 4 Digits of
Social Security #
DEMOGRAPHICS
Middle Name
Additional Family First Name
□Jr
□Sr □___
Suffix
Mother’s First Name
Race
□ White
□ Black
□American Indian/Alaskan
□Asian
□ Hispanic
□Hawaiian/Pacific Islander
Vet
Status
Additional Family Member Language
Health Insurance Type
□ Yes
□ No
1 Language - English Other_________
□MA-IM Care/MN Care
□HMO □Medicare
□Private □None
US Citizen?
Disability?
□ Yes
□ No
□ Yes
□ No
st
2nd Language - Other__________ English
Highest Level of Education
If less than a high school
Trade school or some college
diploma. Highest grade
Associate degree
completed ___________
Bachelor Degree
High school/GED
Graduate or professional degree
Revised 03/27/2013
Average
Weekly Work
Hrs
Please insert Additional Family Members on Back. Thank you.
I certify there are a total of _______ members of my household dependent upon the income I submitted.
I certify the above information is true and correct and that Early Childhood staff may verify the information.
Date
Parent / Guardian Signature
ADDITIONAL
Additional Family Last Name
FAMILY
MEMBERS
□Male
□Female
Relationship to Head of Family (HOF)
□Spouse □Daughter □Son
□Foster Child □Other_________
Date of Birth
Marital Status
□Single □Married
□Separated □Widowed
□Divorced □Living
Together □Never Married
Last 4 Digits of
Social Security #
ADDITIONAL
Additional Family Last Name
□Spouse □Daughter □Son
Date of Birth
Last 4 Digits of
Social Security #
ADDITIONAL
Additional Family Last Name
□ Yes
□ No
1st Language - English Other_________
□ Yes
□ No
□ Yes
□ No
2nd Language - Other__________ English
Highest Level of Education
If less than a high school
Trade school or some college
diploma. Highest grade
Associate degree
completed ___________
Bachelor Degree
High school/GED
Graduate or professional degree
MEMBERS
□Foster Child □Other_________
Date of Birth
Last 4 Digits of
Social Security #
ADDITIONAL
Additional Family Last Name
1st Language - English Other_________
□ Yes
□ No
2nd Language - Other__________ English
Highest Level of Education
If less than a high school
Trade school or some college
diploma. Highest grade
Associate degree
completed ___________
Bachelor Degree
High school/GED
Graduate or professional degree
MEMBERS
□Spouse □Daughter □Son
□Foster Child □Other_________
Early Childhood Application Form 2013-2014
Average
Weekly Work
Hrs
DEMOGRAPHICS
Middle Name
□Jr
□Sr □___
Race
Suffix
Mother’s First Name
□ White
□ Black
□American Indian/Alaskan
□Asian
□ Hispanic
□Hawaiian/Pacific Islander
Vet
Status
Additional Family Member Language
Health Insurance Type
□ Yes
□ No
1st Language - English Other_________
□MA-IM Care/MN Care
□HMO □Medicare
□Private □None
US Citizen?
Disability?
□ Yes
□ No
□ Yes
□ No
2nd Language - Other__________ English
Highest Level of Education
If less than a high school
Trade school or some college
diploma. Highest grade
Associate degree
completed ___________
Bachelor Degree
High school/GED
Graduate or professional degree
MEMBERS
Average
Weekly Work
Hrs
DEMOGRAPHICS
Middle Name
Additional Family First Name
Marital Status
□Single □Married
□Separated □Widowed
□Divorced □Living
□ Black
□American Indian/Alaskan
□Asian
□ Hispanic
□Hawaiian/Pacific Islander
□ Yes
□ No
□Male
□Female
Relationship to Head of Family (HOF)
Mother’s First Name
Health Insurance Type
□ Yes
□ No
FAMILY
Race
□ White
□MA-IM Care/MN Care
□HMO □Medicare
□Private □None
□Male
□Female
□Spouse □Daughter □Son
□Jr
□Sr □___
Suffix
Additional Family Member Language
Disability?
Marital Status
□Single □Married
□Separated □Widowed
□Divorced □Living
Together □Never Married
DEMOGRAPHICS
Middle Name
Additional Family First Name
Relationship to Head of Family (HOF)
Average
Weekly Work
Hrs
Vet
Status
US Citizen?
FAMILY
□ Black
□American Indian/Alaskan
□Asian
□ Hispanic
□Hawaiian/Pacific Islander
Health Insurance Type
□Male
□Female
□Foster Child □Other_________
Mother’s First Name
□MA-IM Care/MN Care
□HMO □Medicare
□Private □None
Disability?
Marital Status
□Single □Married
□Separated □Widowed
□Divorced □Living
Together □Never Married
Race
□ White
Additional Family Member Language
Additional Family First Name
Relationship to Head of Family (HOF)
□Jr
□Sr □___
Suffix
Vet
Status
US Citizen?
FAMILY
DEMOGRAPHICS
Middle Name
Additional Family First Name
□Jr
□Sr □___
Race
Suffix
Mother’s First Name
□ White
□ Black
□American Indian/Alaskan
□Asian
□ Hispanic
□Hawaiian/Pacific Islander
Vet
Status
Additional Family Member Language
Health Insurance Type
□ Yes
□ No
1st Language - English Other_________
□MA-IM Care/MN Care
□HMO □Medicare
□Private □None
2nd Language - Other__________ English
Revised 03/27/2013
Together □Never Married
Date of Birth
Early Childhood Application Form 2013-2014
Last 4 Digits of
Social Security #
US Citizen?
Disability?
□ Yes
□ No
□ Yes
□ No
Highest Level of Education
If less than a high school
Trade school or some college
diploma. Highest grade
Associate degree
completed ___________
Bachelor Degree
High school/GED
Graduate or professional degree
Revised 03/27/2013
Average
Weekly Work
Hrs