ELNC 2020/2021 Application – ELNC – Early Learning Neighborhood Collaborative

Applicant

Name

First Middle Last Suffix

Nickname

Date of Birth

MM

DD

YYYY

Gender

Male
Female

Race

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

Federal Definition - Select all that apply.

Hispanic?

Yes
No

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Medicaid Eligibility

Medicaid Number

Doctor / Medical Home

Dental Coverage

Dentist / Dental Home

Primary Adult

Name

First Middle Last Suffix

Email

Nickname

Date of Birth

MM

DD

YYYY

Gender

Male
Female

Race

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

Federal Definition - Select all that apply.

Hispanic?

Yes
No

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Yes
No

Check All That Apply:

Lives With Family
Provides Financial Support
Teen Parent

Subsidized?

Yes
No

Secondary or Other Adult

Name

First Middle Last Suffix

Email

Nickname

Date of Birth

MM

DD

YYYY

Gender

Male
Female

Race

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

Federal Definition - Select all that apply.

Hispanic?

Yes
No

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Yes
No

Check All That Apply:

Lives With Family
Provides Financial Support
Teen Parent

Subsidized?

Yes
No

Additional Child (Non-Applicant)

Name

First Middle Last Suffix

Nickname

Date of Birth

MM

DD

YYYY

Gender

Male
Female

Race

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

Federal Definition - Select all that apply.

Hispanic?

Yes
No

English Proficiency

Other Language

Other Language Proficiency

Additional Child (Non-Applicant)

Name

First Middle Last Suffix

Nickname

Date of Birth

MM

DD

YYYY

Gender

Male
Female

Race

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

Federal Definition - Select all that apply.

Hispanic?

Yes
No

English Proficiency

Other Language

Other Language Proficiency

Family Information

Family Living Address

Street Address Address Line 2 City State ZIP Code

Started Living At Date

MM

DD

YYYY

Family Mailing Address - Same as Living Address?

Yes
No

Family Living Address

Street Address Address Line 2 City State ZIP Code

Phone Number(s)

Type

Note (Extension / Best Time to Call, etc.)

Opt-In for Text Messages

Yes
No

List Additional Number(s)

Yes
No

#2 Phone Number(s)

Type

Note (Extension / Best Time to Call, etc.)

Opt-In for Text Messages

Yes
No

#3 Phone Number(s)

Type

Note (Extension / Best Time to Call, etc.)

Opt-In for Text Messages

Yes
No

Parental Status

Primary Language at Home

Homeless Family?

Yes
No

Active Military Duty?

Yes
No

Military Veteran?

Yes
No

Referred by Child Welfare Agency?

Yes
No

Receiving SNAP?

Yes
No

WIC?

Yes
No

Family Income

TANF Status

Yes
No
Formerly on TANF / Not Now

SSI?

Yes
No

1.) Family Member

First Last

Amount Per:

Example: $500 per week or $40,000 per year

Annual Amount

Description

Example: SSI, Job, Child Support, etc.

2.) Family Member

First Last

Amount Per:

Example: $500 per week or $40,000 per year

Annual Amount

Description

Example: SSI, Job, Child Support, etc.

3.) Family Member

First Last

Amount Per:

Example: $500 per week or $40,000 per year

Annual Amount

Description

Example: SSI, Job, Child Support, etc.

Location Preference Priority

1st Priority (List Site and Classroom)

2nd Priority (List Site and Classroom)

3rd Priority (List Site and Classroom)

Preschool Eligibility Criteria

Special Needs

Child Diagnosed with Special Needs (Active IEP, Screened Assessment)
Referral by Health/Medical, Educational or Social Service Agency

Check all that apply.

High Social Service Need

Referral from Child Protective Services, Child Protective Services Involved Now/Past
Parent/Guardian Incarcerated Now/Past
Currently Experiencing Homelessness
Child Currently in Foster Care

Check all that apply.

Circumstances Affecting Families

Primary Language in the Home Other than English
Non-Completion of High School or GED
Residing within ELNC Targeted Neighborhoods
Baby Scholars Graduate

Check all that apply.

Employment Status

Adult in Family Unemployed

Check all that apply.

Certification

*

I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.

Parent/Guardian Signature*

Date*