Enrollment Application

Post author By rchsccn

If you need help or have questions…

Thank you for considering us for your child’s early care and education. We look forward to getting to know you and your child soon.

Please do not hesitate to contact us by phone during business hours, or by our contact form if after hours.

Child’s Name*
First Middle Last
Sex/Gender
- Male
- Female
- Other
Ethnic Origin
Native Language
Birth Date*
MM slash DD slash YYYY
Age of child on upcoming Sept 1st
- 3
- 4
- 5
Social Security Number*
Phone – home*
Phone – cell
Phone – message
Insurance Company
Name of Emergency Contact Person #1*
First Last
Phone of Emergency Contact Person #1*
Name of Emergency Contact Person #2*
First Last
Phone of Emergency Contact Person #2*
Town of Residence
Mailing Address
Street Address Address Line 2 City State ZIP Code
Physical Address
Street Address Address Line 2 City State ZIP Code
Do you need child care?
- Yes
- No
Family Information
Child lives with:
Mother’s Name
First Last
Mother’s Address
Street Address Address Line 2 City State ZIP Code
Mother’s Email
Enter Email Confirm Email
Mother’s Date of Birth
MM slash DD slash YYYY
Mother’s highest school grade completed
- 8
- 9
- 10
- 11
- 12
- Some College or Technical School
- College Degree
Place of Employment
Work hours: From what hour to what hour?
Mother’s Work Phone
Father’s Name
First Last
Father’s Address
Street Address Address Line 2 City State ZIP Code
Father’s Email
Enter Email Confirm Email
Father’s Date of Birth
MM slash DD slash YYYY
Father’s highest school grade completed
- 8
- 9
- 10
- 11
- 12
- Some College or Technical School
- College Degree
Place of Employment
Work hours: From what hour to what hour?
Father’s Work Phone
Family Income
Father’s income $
Mother’s income $
Other household income $
My family receives the following benefits: Please check all that apply.
If there are other children in the household, please list names, sex, dates of birth, current grade in school, and if handicapped.
If there are other ADULTS in the household, please list names and relationships to the head of household.
Total number living in household
Additional Information
How did you hear about Rutland County Head Start?
Does child have a diagnosed medical condition? (asthma, allergy, etc…)
Does child have a diagnosed disability? (developmental delay, cerebral palsy, etc…)
Is child receiving services related to disability?
Is child atteending any other programs? (EEE, Kids on the Move, etc…)
Certification

By signing my name electronically below, I affirm that I understand all information and certify this information to be correct to the best of my knowledge. I fully intend to enroll my child in the program if he/she is accepted. I agree to comply with the rules and regulations of the program. I understand that the information provided above will remain strictly confidential.
Electronic Signature of Parent or Guardian*
Date Signed*
MM slash DD slash YYYY
The following section will be completed by staff after submission.
Signature of Staff Member
Date Signed
MM slash DD slash YYYY

If you need help or have questions…

Family Information

Family Income

Additional Information

Certification

The following section will be completed by staff after submission.