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About Siletz news / (Siletz, OR) 199?-current | View Entire Issue (May 1, 2006)
TRIBAL PROGRAM NEWS Siletz Tribal Head Start Enrollment Application Siletz Tribal Head Start 2006-2007 Family Needs Assessment Return this application to Siletz Tribal Head Start, PO Box 549, Siletz, OR 97380. For more information, call 1-800-922-1399, ext. 1376, or 541-444-8376. Siletz Tribal Head Start is conducting a survey to identify needs that exist in our community and determine what programs and services would be relevant for Head Start to offer in the future. Your assistance will help us to design pro grams to meet the needs of the community. Thanks for your input and support. 2006-07 year 1. Child’s Name: 3. Child’s Sex: Check One (Optional): __ Native American___ Other____________ ________________________ 2. SSN:_____ -____ -______ M F (circle one) Age: Returning Student Yes No 4. Date of Birth______ -_____ -_____ 5. Does your child have any condition that may be considered a disability or special need? No Yes Please explain:___________________________ (please attach verification) 6. Is child member/descendant of a federally recognized Indian Tribe? No Yes County Address Family Data Two-Parent Household o Single Parent Household o Guardian o Grandparent o Total Number of Household Members:_____ Total Number of Children in Family:____ Age(s) of Children:_____________ Roll #__________ Tri be(s)__________________ (please attach verification) Primary language spoken in the home:______________________________ Foster Parent o Does any child have any condition that may be considered a disability or special need? _ No __ Yes 7. Parent/Guardian( 1 ):_________________ ___________________________ Please explain:____________________________________________________ Date of Birth:______ -_____ -_____ SSN:_____ -____ -______ Primary language spoken in the home:________________________________ Street AND Mailing Address:_________________________________________ City:_________________ State:________________ ZIP Code:______________ Economic Information: Parent(s) Employed: ____Full-time____ Part-time ___In Training/School ____ Not Employed Telephone: Home:(___)_________ Work:(___ )_________ Message:----------------- Gross Monthly Income:______________ Parent/Guardian(2):______ _________________________________________ Highest Grade Completed by Caregiver:________ Date of Birth:______ -_____ -_____ SSN:_____ ------- ---------- Street AND Mailing Address:________________________________________ City:_________________ State:______________ ZIP Code:______________ Does Family Receive: ___ TANF ___ Food Stamps ____ Other_________________________ ____SSI ____GA Do you own or rent your home?_____________ Cost per month____________ Are you hornless?__________________ Telephone: Home:(___)_________ Work:(__ )_________ Message:---------------- 8. A preference for enrollment can be given to families that face any of the following conditions: single parents, parents separated/divorced, child is a vic tim of abuse or neglect, or child suffers from a non-handicapping condition, or sibling attends our program. If your family meets this criteria and you would like to claim that preference, please list the conditions here:-------------------------- Transportation Do you have reliable transportation? _ Yes Do you have access to public transportation? __No _ Yes Child Care Do you have children in child care now? _ Yes What is the hourly/monthly rate?__________ __No __ No 9. List all other household members by name and date of birth: How would you rate your child care? _ Poor 1._____________________________ 2._____________________________ Have you had any problems accessing child care services?_ Yes 3._____________________________ 4._____________________________ Which of the following would best meet you needs: _ Home-Based Head Start _ Center-Based Head Start 5._____________________________ 6._____________________________ 10. Financial Statement: Monthly Income_______________ (you must attach verification of these benefits) __Good _Fair __Tremendous __ No Would it benefit you if Siletz Tribal Head Start served families for 12 full months? _ Yes __ No Would it benefit you if our program served children ages 0-3?_ Yes __ No 11. With my signature I certify that the above information is accurate: Would it benefit you if Head Start were to offer an all-day program from 7 a.m. to 6 p.m? _ Yes __ No Signature: Date: For office use only: Date Received____________ Staff Initials------------- Siletz Tribal Head Start is an equal opportunity program and open to all children regardless of race, age, sex, handicap, or national origin. Any person who believes he/she has been discriminated against should write to the Secre tary of Agriculture, Washington, DC 20250. Please rate the following from highest to lowest priority of need; I = highest priority to 14 = lowest need. _Employment ____ Recreation ____Health Care ____ Child Care ___ Alcohol & Drug ____Adult/Higher Education ____ Housing ____ Dental Care ____ Parenting Awareness May 2006 • Preschool/Head Start ___ Nutrition ___ Cultural Activities ___ Other Siletz News • 9
