Head Application Form Name: MI: Last Name:   DOB:* Gender: Male Female Race*(Check only one) Ethnicity: (Please specify below)  American Indian/Alaskan Native Hispanic/Latino  Asian Native Hawaiian or Other Pacific Islander  Person’s Ethnicity is Latino or Black or African American White How well does the child speak English? Bi-racial/Multi-Racial Specify  Very well Well Other Specify  Not well Not at all Unknown    Language spoken at home: Primary English Spanish Other _ _    Secondary English Spanish Other _ _ LIVING ADDRESS Street Address: Apt. # City: State: Zip Code: School District: MAILING ADDRESS Same as living address □ Street Address: Apt. #: City: State: Zip Code: PARENT/GUARDIAN Name: MI: Last Name: DOB:*   Gender: Male Female Phone: Email address:   Can you receive texts? Yes No Marital Status: Person is Head of Household:      Married Single Separated Divorce Partner Yes No Relationship to Child:     Biological parent Grandparent Parent’s significant other Foster Parent Legal guardian  Step Parent   Is person currently pregnant? Yes No   If yes, when is due date: Person lives in same household as child? Yes No
Head Application Form Name: MI: Last Name: DOB:* Gender:  Male  Female Race*(Check only one) American Indian/Alaskan Native  Hispanic/Latino Asian  Native Hawaiian or Other Pacific Islander Black or African American  White Bi-racial/Multi-Racial Specify Other Specify Unknown Ethnicity: (Please specify below) Person’s Ethnicity is Latino or How well does the child speak English? Very well  Well Not well  Not at all Language spoken at home: Primary  English  Spanish  Other _ _ Secondary  English  Spanish  Other _ _ LIVING ADDRESS Street Address: Apt. # City: State: Zip Code: School District: MAILING ADDRESS □ Same as living address Street Address: Apt. #: City: State: Zip Code: PARENT/GUARDIAN Name: MI: Last Name: DOB:* Gender:  Male  Female Phone: Can you receive texts?  Yes  No Email address: Marital Status: Married  Single  Separated  Divorce  Partner Person is Head of Household: Yes  No Relationship to Child: Biological parent  Grandparent  Parent’s significant other  Foster Parent  Legal guardian Step Parent  Person lives in same household as child?  Yes  No Is person currently pregnant?  Yes  No If yes, when is due date:
2015-Application-Packet.docx