ENGLISH
Division Title I & of Early Childhood Programs and Services
Prekindergarten/Head Start Unit
MONTGOMERY COUNTY PUBLIC SCHOOLS
Rev. 1/16
Affix Ticket Here
LOG-IN SHEET
Today’s Date: _________/_________/_________
LOG-IN #:____________________
Child’s Last
Child’s First
Child’s Middle
Name: ________________________________________ Name: ______________________________ Name: ____________________
Child’s
Date of Birth: __________/___________/__________
Month
Day
Year
(Ages 3 or 4 by September 1, 2016) Age  3
Street Address: _______________________________________________________________
City: __________________________________________________
State:
MD
4
Apt. #: ______________
Zip Code: _______________
Father’s
In Home
Mother’s
In Home
Name: ______________________________________ Yes  No Name: ______________________________ Yes  No
Home
Work Phone #’s:
Cell Phone #’s:
Phone #: __________- __________-_________ (Mother) ________- ______ -________ (Mother) ______ - ______ - ______
E-mail: ________________________________
(Father) ________- ______ -________ (Father) ______
- ______ - ______
Is your child a U.S. Citizen?  Yes
 No
If no, do you have a SCRIA (School Counseling, Residency and International Admissions) folder?  Yes  No
DO NOT WRITE IN BOX BELOW
(STAFF ONLY) REVIEW, CHECK BOXES AND COLLECT ALL DOCUMENTS TO COMPLETE APPLICATION.
SCREENED BY:____________________
PROOF OF INCOME (REQUIRED)
 2015 1040 TAX STATEMENT, W-2 AND 3 PAYSTUBS
OR SCH “C” AND 1099, IF SELF-EMPLOYED
 NOTARIZED LETTER FROM EMPLOYERS
 PROOF OF ADDITIONAL INCOME (TCA LETTER,
CHILD SUPPORT, RENTAL INCOME, UNEMPLOYMENT, ETC.)







CHILD’S BIRTH CERTIFICATE (REQUIRED)
PARENT’ PHOTO I.D. (REQUIRED)
CHILD’S SOCIAL SECURITY CARD
CHILD’S MEDICAL CARD
FOOD STAMP LTR
 WIC
POC/WPA (CHILD CARE VOUCHERS)
CUSTODY PAPERS
 Homeless
 Foster Care
 Current IEP  Previous School Experience: WHERE: __________________
 MISSING DOCUMENTS (GAVE COPY OF BLUE SHEET)
___________________________________________
_________________________________________
_________________________________________
__________________________________________
_________________________________________
__________________________________________
 OVER INCOME (GAVE WHITE RECEIPT; GAVE PK EXPANSION INFORMATION)
HOME SCHOOL: ___________________
APPLICATION TAKEN BY: ___________________________
Affix Label Here
PROOF OF RESIDENCY (REQUIRED)
 CURRENT PROPERTY TAX BILL (IF HOMEOWNER)
 LEASE AND CURRENT UTILITY BILL, (IF RENTER) AND HOC LETTER, IF APPLICABLE
 NOTARIZED SHARED HOUSING AND CURRENT PROPERTY TAX BILL OR LEASE; AND LEASEHOLDER’S CURRENT
UTILITY BILL; AND 3 DOCUMENTS
________
Category
3
4
OFFICE USE ONLY
DATE ENTERED INTO COMPUTER _____/_____/______
INITIALS __________
Revised 1/16
Prekindergarten/Head Start Income Eligibility Form
Please complete the following:
A. CHILDREN INFORMATION. List ALL children enrolled in Montgomery County Public Schools ONLY. Use additional paper if needed. Include Prekindergarten/Head Start applicant.
Last Name
First Name
Middle Name
1.
Relationship
Student ID #
Birth Date
Grade
School
B. CASE NUMBER
Pre-K/HS child
4.
If applicable give a Food Supplement
Program (FSP) (formerly Food Stamps)
or nine-digit Temporary Cash Assistance
(TCA) case number for any member of the
household.
5.
___ ___ ___ ___ ___ ___ ___ ___ ___
2.
3.
6.
C. FOSTER CHILDREN. Check here ____ if you are applying for meal benefits for a foster child living with you, please list child’s personal monthly income $__________. Name of child _______________
D. IF ANY CHILD YOU ARE APPLYING FOR IS HOMELESS, MIGRANT, OR A RUNAWAY, CHECK ONE: __HOMELESS __MIGRANT __RUNAWAY and call your school or Homeless Liaison at 301-279-3322.
E. ALL OTHER HOUSEHOLD MEMBERS. List all other people living in the household. Your household includes all those living as one economic unit – including yourself and anyone living with you,
whether or not they are related to you, including all children not listed above.
List all current household income before expenses and deductions for taxes, etc., and how often it is paid: weekly (wk), every two weeks (bi-wk), twice a month (twice), or monthly (mo).
Last Name
First Name
Relationship
to child
Earnings from Work
before deductions
Job 1
Marital Status
Amount
Earnings from Work
before deductions
Job 2
How Often
Amount
All Other Income
Child Support, Alimony, TCA,
Disability, Social Security
How Often
Amount
1.
$
$
$
2.
$
$
$
3.
$
$
$
4.
$
$
$
5
$
$
$
6.
$
$
$
7.
$
$
$
8.
$
$
$
How Often
F. SIGNATURE AND SOCIAL SECURITY NUMBER. I certify that all the above information is true and that all income is reported. I understand that this information is being given for the school's receipt of
federal funds; that school officials may verify the information. Falsification of any information submitted may be cause for rejection of this application or removal from the program after placement.
Signature, Adult in Household ____________________________________ Date ___/___/___
G. OFFICE USE ONLY
--

Family Size ___________________
Special Circumstance (needs review)
Social Security #
Total Income
 Yes  No
I do not have a Social Security Number.
_____________________________________
Category _______________
Comments: _____________________________________________________________________________