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
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