Rapides Early Childhood Network

Center Choice

Head Start/Early Head Start*

STUDENT INFORMATION

First Name*

Middle Name*

Last Name*

Check here if this student does not have a middle name.

Suffix

Gender*

Birth Date *

Does this child have a pupil Appraisal Evaluation and IEP for an identified disability?*

Physical Home Address

Post office address will not be processed.

Address*

City*

State*

Zip code*

Primary Phone*

Is there a different mailing address?*

STUDENT INFORMATION 2

First Name

Middle Name

Last Name

Check here if this student does not have a middle name.

Suffix

Gender

Birth Date

Does this child have a pupil appraisal evaluation and IEP for an identified disability?

Physical Home Address

Post office address will not be processed.

Address

City

State

Zip code

Primary Phone

Is there a different mailing address?

STUDENT INFORMATION 3

First Name

Middle Name

Last Name

Check here if this student does not have a middle name.

Suffix

Gender

Birth Date

Does this child have a pupil Appraisal Evaluation and IEP for an identified disability?

Physical Home Address

Post office address will not be processed.

Address

City

State

Zip code

Primary Phone

Is there a different mailing address?

STUDENT INFORMATION 4

First Name

Middle Name

Last Name

Check here if this student does not have a middle name.

Suffix

Gender

Birth Date

Does this child have a pupil Appraisal Evaluation and IEP for an identified disability?

Physical Home Address

Post office address will not be processed.

Address

City

State

Zip code

Primary Phone

Is there a different mailing address?

STUDENT INFORMATION 5

First Name

Middle Name

Last Name

Check here if this student does not have a middle name.

Suffix

Gender

Birth Date

Does this child have a pupil Appraisal Evaluation and IEP for an identified disability?

Physical Home Address

Post office address will not be processed.

Address

City

State

Zip code

Primary Phone

Is there a different mailing address?

STUDENT INFORMATION 6

First Name

Middle Name

Last Name

Check here if this student does not have a middle name.

Suffix

Gender

Birth Date

Does this child have a pupil Appraisal Evaluation and IEP for an identified disability?

Physical Home Address

Post office address will not be processed.

Address

City

State

Zip code

Primary Phone

Is there a different mailing address?

+ Add Another Student

Ethnicity and Race Information

Ethnic/gender information is collected but not used for selection.

Ethnicity

Is this student Hispanic/Latino? (Defined as a person of Cuban, Mexican, Puerto Rican, Sout or Central American, or other Spanish culture or origin, regardless of race.) *

Yes, Hispanic/Latino

No, Hispanic/Latino

Race

What is the student's race? Choose one or more.

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Mother

First Name

Last Name

Does this parent/guardian live at the address listed above?

Cell Phone

Email Address Email address will be used for emergency and event notification

Employer

Check if this Parent/Guardian does not have an email address.

Father

First Name

Last Name

Does this parent/guardian live at the address listed above?

Cell Phone

Email Address Email address will be used for emergency and event notification

Employer

Check if this Parent/Guardian does not have an email address.

Employer

Total Number in Household*

Number of Children in Household (Age less than 18 years)*

How many household members have income?*

Is your household's total monthly gross earned and unearned income less than the amount listed below for your household size? (gross income refers to income before any deductions from the paycheck):

2 persons: $1,526
3 persons: $1,919
4 persons: $2,313
5 persons: $2,706
6 persons: $3,099
7 persons: $3,493
8 persons: $3,886
9 persons: $4,279

Yes No

Failure to provide income could result in automatic ineligibility for Head Start.

Referral

If my child is not placed through this application, I would like to be referred through the Rapides Early Childhood Network (RECN) for placement options. The network has permission for the child's information to be released to other program sites for enrollment purposes.*

Parent/Guardian Signature

Rapides Parish School District treats the following signature like a signature on a paper form.

** No child/family may be denied admission or participation or be discriminated against because of sex, race, religion, national origin, ancestry, creed, pregnancy, marital or parental status, sexual orientation, or physical, mental, emotional, or learning disability.

By signing this form electronically, you acknowledge that duplicate entries for this student can result in disqualification from the process.

Type full name*

date*

Email Confirmation

Email Address* Email address will be used for emergency and event notification

Note: Please review your information carefully. Once the submit button is pressed, you will no longer be able to change the information entered. Changes to your information can only be made in person at the district Early Childhood office.

submit

Head Start Application