Summit Head Start 0-5
PO Box 497- 330 Fiedler Ave. suite 206 & 209
Dillon, CO 80435
Fax 970.468.7923
Application
Thank you for your interest in Early Head Start/Head Start.
Summit Head Start 0-5 is able to serve 35 children ages 3-5 and 24 children ages prenatal to 3.
Head Start programs HAVE NO FEE for families who qualify. Families with children with special
needs and severe disabilities are encouraged to apply. Early Head Start and Head Start
programs provide comprehensive family services for pregnant women and families with children
ages birth to 5. We work in partnership with the families and the community in providing
comprehensive services, including health, education and self- sufficiency through home
visitation, childcare or preschool.
We take pride in participating in an integrated program model within the school district
preschools, community based center programs, and home visitation program. We focus on the
importance of child initiation, creative play, hands-on discovery, and continuous exposure to
developmentally appropriate activities for each child. Full day preschool programs are available
for children 3-5. Home Visitation and Child Care are available for prenatal to age 3.
Our Head Start program is a partnership between Summit County Government, Summit School
District, Early Childhood Options, Summit County Preschool, and the Family and Intercultural
Resource Center.
As part of the process of recruiting eligible children and their families, the following
information is required. Please complete and return the following to us:
- Completed Application
- Signed Interagency Release
- Family Income verification for the last 12 months
(W-2, tax documents, pay stubs, employer letter verifying income)
- Copy of Child’s Birth Certificate
We accept applications year round, and always maintain a waitlist.
Director
Elizabeth Lowe 970.406.3063
Mental health Consultant
Katharine Orr 970.406.3060
Family Engagement Specialists
Carly Nixon 970.406.3069
Paulina Cuadrado 970.406.3061
Data & Systems Manager
Emily Schwier 970.406 3066
Summit Head Start 0-5
Eligibility Application
Please fill out application completely. All the information will be kept confidential and only shared to determine
appropriate placement.
Name of child:
Last Name(s)
First Name
Date of birth (mm/dd/yyyy):
Gender:
Has your child previously been enrolled in Head Start or Early Head Start?
Middle Name
Male
Yes
Female
No
If yes, please write the name of the program:
How did you hear about Head Start?
Race:
White
Black/African American
Ethnicity:
Native American/Alaskan Native
Native Hawaiian or Pacific Islander
Hispanic/Latino
Child’s primary language:
English proficiency:
None
Family type:
Two parent household
Single parent
Parent lives with a partner
Parents are divorced/separated
Asian
Bi-racial
Non-Hispanic or Non-Latino
_______________________
Poor
Average
Phone number __________________
Fluent
Blended family
Foster family
Child lives with other relative(s)
Parent/Guardian #1
Name: _______________________________________________________ DOB:_________________________
Relationship to child: __________________________________________ Lives with child?
yes
No
Provides Financial support?
yes
No
Highest grade completed
9 grade or less
Some High School
High school Diploma/GED
Some College
Associates Degree
Bachelor’s Degree
Master’s Degree
Doctorate
Employment Status
Place of employment __________________________________
Full time
Part Time
Unemployed
Disabled
Full time student
Part time student
Home maker
E-mail address: _______________________________________________ Phone number _______________
Language: _________________________ English Proficiency
None
Poor
Average
Fluent
Are you pregnant?
Yes
No
Does not apply
Due date? ______________________
Parent/Guardian #2
Name: ________________________________________________________ DOB:_________________________
Relationship to child: __________________________________________ Lives with child?
yes
No
Provides Financial support?
yes
No
Highest grade completed
9 grade or less
Some High School
High school Diploma/GED
Some College
Associates Degree
Bachelor’s Degree
Master’s Degree
Doctorate
Employment Status
Place of employment ________________________________
Full time
Part Time
Unemployed
Disabled
Full time student
Part time student
Home maker
E-mail address: _______________________________________________ Phone number _______________
Language: _________________________ English Proficiency
None
Poor
Average
Fluent
Are you pregnant?
Yes
No
Does not apply
Due date? ______________________
2015-16 Eligibility Application
-1-
Summit Head Start 0-5
General Information
Mailing Address:
Physical Address:
(If different)
Alternate contact person:
Home visitation for EHS (0-3 year olds)
State
Zip Code
City
State
Zip Code
Phone number:
(Someone not living with you)
School of preference
Dillon Valley Elementary
Upper Blue Elementary
City
Silverthorne Elementary
Summit Cove Elementary
Summit County
Preschool
Childcare for EHS (0-3 year olds)
Number of family members living with the child ______________
Name _______________________________ Gender ____ DOB ____________
Name _______________________________ Gender ____ DOB ____________
Name _______________________________ Gender ____ DOB ____________
Name _______________________________ Gender ____ DOB ____________
Relationship ________________
Relationship ________________
Relationship ________________
Relationship ________________
Type of services family is currently receiving (mark all that apply):
No services received
CHIP
TANF -Public assistance/welfare
Public housing
Unemployment benefits
Child support/alimony
LEAP - Energy program assistance
Foster care/adoption subsidy
Medicaid/Medicare
Food Stamps (SNAP)
SSI-Supplemental Security Income
WIC- Women, Infant, Children
Kinship assistance
Other (please list):
Family circumstances within the immediate household (mark all that apply):
Family member with disability/special need
Substance abuse/treatment
Family member with medical issue
Early intervention
Family member with mental illness
Incarcerated family member
Loss of family member through separation
Domestic violence
Loss of family member through divorce
Abuse/neglect
Loss of family member through death
Not Applicable
Parent deployed (in the last 12 months)
Was the oldest child born when parent was under 18 years of age
Father
At least one parent/Guardian is a member of the Unites Stated Military
Mother
Yes
N/A
No
In the last 12 months, did you live in a car, domestic violence shelter, homeless shelter, campground, park, or with another
family or relative due to loss of housing or economic hardship?
Yes (Please circle which one)
No
How many times has the family moved in the last 2 years? 0
1
2
3 4
To the best of my knowledge, the information given in this application is accurate and true. I also
understand that failure to respond to all questions truthfully may negatively impact my child’s placement.
Completion of this application does not guarantee enrollment in any program.
Parent Signature: ___________________________________________ Date: ________________
2015-16 Eligibility Application
-2-
Summit Head Start 0-5
Child’s name:
____________
Date of birth:
Special Needs Concerns
1. Do you have any concerns about your child?
Yes
If yes, mark in which areas:
_____________
No
Date diagnosed by a professional (if applicable)
Speech and language (in primary language)
______________
Emotional & behavioral concerns
______________
Ability to learn
______________
Physical impairment
______________
Health impairment
______________
Autism
______________
Traumatic brain injury
______________
Head injury/concussion
______________
Vision impairment (including blindness)
______________
Hearing impairment (including deafness)
______________
Other (please explain)
______________
Please explain your concerns:
2. Has your child ever received special education services or early intervention?
3. Is your child on an Individualized Education Plan (IEP)?
Yes
Yes
No
No
If yes, please write where child was attending:
4. Is your child on an Individualized Family Service Plan (IFSP)?
Yes
No
If yes, please write where child was attending:
5. Do you have any special education documentation?
Yes
No
Not applicable
*If you marked yes to any of these questions, please fill out a Release of Information form.
List any additional information you would like us to be aware of:
Specialist/Clinic/School District working with child (if applicable):
Location or address:
Telephone :
To the best of my knowledge, the information given in this application is accurate and true. I also understand that
failure to respond to all questions truthfully may negatively impact my child’s placement. Completion of this
application does not guarantee enrollment in any program.
Parent/guardian signature:
Parent/guardian name (printed):
2015-16 Eligibility Application
Date:
______________________
______--3-
Consent for the Release of Confidential Information –
Summit Head Start 0-5
Child’s Name: _______________________________________ Date of Birth: __________________
I, _______________________________ (printed name of parent/guardian), hereby authorize the Summit
County Early Head Start & Head Start (SCEHS/HS) Program to 1) include the information I provide on
enrollment and assessment paperwork in confidential, secure databases*, 2) share my child’s name and DOB
with Summit School District in order to track long-term outcomes for EHS/HS participants, and 3) disclose and
exchange information about my case with relevant SCEHS/HS employees and the following
organizations/programs:
SCEHS/HS Partners—The Summit County Head Start 0-5 Program partners with several agencies to deliver program
services. It will be necessary for us to share child information to determine enrollment and maintain enrollment with the
following:
Early Childhood Options (ECO)
High Country Healthcare (HCHC)
Family & Intercultural Resource Center (FIRC)
Results Matter (state ECE initiative)
Summit County Government-Youth & Family
-Community Infant Child Program (CICP)
Summit County School District
Summit County Government-Public Health
-Early Intervention Colorado (EI)
-Public Health Nurses
-Women Infants & Children Program (WIC)
Summit County Preschool
Summit County Right Start Project (county ECE initiative)
________Please initial once reviewed with EHS/HS
staff.
Health Tracking—If enrolled, EHS/HS is required to track health information. Please provide names of your health providers
so we may contact them to share medical information.
Health Care Providers: _______________________________________________________________________________________
Dental Care Providers: _______________________________________________________________________________________
Other: ___________________________________________________________________________________________________
Please inform EHS/HS staff if you change providers and/or visit new providers.
_________Please initial once reviewed with EHS/HS staff.
Additional Support—To support you and your family, we work with many other community partners. Please initial the
additional organizations you allow us to share information with.
_____
_____
_____
_____
_____
Advocates for Victims of Assault
Colorado Child Care Assistance Program
Colorado Mountain College (ESL & Family Literacy)
Colorado Workforce Center
Summit County Child Care Centers
_____
_____
_____
_____
_____
Holiday Donation Agencies
General Assistance Programs
Nurse Family Partnership
Summit County Care Clinic
Summit County Social Services**
Other:
*Names of databases given upon request. **SCEHS/HS staff members are required by law to report any suspected abuse and/or neglect.
I consent and understand that I can revoke my permission to release confidential information at any time. I understand
that this release of information is valid while the child is enrolled in the Summit County Early Head Start & Head Start
Program or for 5 years from the data it is signed unless I sign for revocation of consent.
______________________________________________________
Parent/Guardian Signature
__________________________
Date
______________________________________________________
EHS/HS Staff Signature
__________________________
Date
\
For Revocation of Consent Only
Date: ______________________________________________________________________________________________________________
Parent/Guardian1/2/2015
Signature: _____________________________________________________________________________________________
Staff Signature: ______________________________________________________________________________________________________