1 ABORIGINAL HEAD START APPLICATION FOR 2017-2018_ (bio) step- father ... aboriginal learner data...

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Transcript of 1 ABORIGINAL HEAD START APPLICATION FOR 2017-2018_ (bio) step- father ... aboriginal learner data...

  • 1

    c/o the amiskwaciy Cultural Society (Revised May 2017) Page 1

    CHILD AND FAMILY INFORMATION

    Program Site: _________________ Childs ID Number: ________________

    Class: AM PM Start Date: ______________________

    New Returning

    Intake Date: ______________________

    (For office use only)

    Childs Legal Name:

    _________________ _____________________ ____________________ (First) (Middle) (Last)

    Other known name(s): _____________________________________________________

    DOB: ________________________ Gender: Male Female (Month / Day / Year) Address: ______________________Suite #:___________ Postal Code: ______________

    Home Phone: _______________ Work: _________________ Cell: __________________

    Email Address: __________________________________________________________________

    Name of Primary caregiver: ________________________ _______________________

    (First) (Last) Relationship to child:

    Mother (bio) Step-Mother Father (bio) Step-Father Grandmother

    Grandfather Aunt Uncle Foster parent Other _________________________________

    Address: Same as child? Yes No

    Name of Additional caregiver (if any): ____________________ ____________________

    (First) (Last) Relationship to child:

    Mother (bio) Step-Mother Father (bio) Step-Father Grandmother Grandfather

    Aunt Uncle Foster parent Other ___________________________________

    Address: Same as child? Yes No

    Address: ______________________Suite #:___________ Postal Code: _______________

    Home Phone: _______________ Work: _________________ Cell: ___________________

    ABORIGINAL HEAD START

    APPLICATION FORM

  • 2

    c/o the amiskwaciy Cultural Society (Revised May 2017) Page 2

    How many times have you moved in the last year? ___________________________

    ALTERNATE PICK UP / EMERGENCY CONTACT INFORMATION

    *PLEASE NOTE A PARENT LIVING IN THE HOME IS NOT CONSIDERED AN

    ALTERNATE PICK UP, AND THE EMERGENCY CONTACTS MUST LIVE WITHIN THE

    EDMONTON CITY LIMITS AND HAVE A WORKING LOCAL PHONE NUMBER

    Contact #1: __________________ _______________________________ (First) (Last)

    Home Phone Number: ___________________ Cell Phone: ___________________

    Address: ________________________ Work Phone: ____________________

    Relationship to the Child: ____________________________________________

    Contact 2 #: ____________________ _______________________________

    (First) (Last)

    Home Phone Number: __________________ Cell Phone:_____________________

    Address: ___________________________ Work Phone: __________________

    Relationship to the child: ____________________________________________

    Alternate Caregivers

    I _________________________ (first/last name of caregiver) give my consent for the persons listed above to pick up my child from the bus or school with proof of identification and prior notification to both the bus driver and classroom teacher. Further, the persons listed above will act as my childs emergency contacts in the event of my absence.

    Parent / Caregiver

    Name: _________________________

    Signature: ____________________

    Date: _______________________ (Month / Day / Year)

    Is anyone denied access to the child? Yes No

    Who is denied access to the child? #1 ________________ _________ _______ (FIRST NAME) (LAST NAME)

    If applicable Are custody documents on file? Yes No

  • 3

    c/o the amiskwaciy Cultural Society (Revised May 2017) Page 3

    Is this your childs first Head Start program? Yes No

    If No, date previously attended and where child attended:

    __________________________________________________________

    (Month / Day / Year)

    ABORIGINAL LEARNER DATA COLLECTION INITIATIVE

    (Enrollment Type)

    It is mandatory that this question is included on registration forms, however answering the

    question is not mandatory.

    If you wish to declare that your child is an Aboriginal person, please specify:

    331 Status Indian / First Nations 334 Inuit

    332 Non-Status Indian / First Nations 333 Mtis

    CHILDS CITIZENSHIP STATUS

    CANADIAN CHILD OF A CANADIAN CITIZEN

    PERMANENT RESIDENT/LANDED IMMIGRANT STUDENT AUTHORIZATION-VISA

    CHILD OF AN INDIVIDUAL LAWFULLY ADMITTED TO TEMPORARY RESIDENTS

    CANADA FOR PERMANENT CITIZENSHIP

    INCOME DECLARATION

    ANNUAL FAMILY INCOME:

    LESS THAN $12,000 $12,000 - $15,000 $15,001 - $18,000 $18,001 - $21,000

    $21,001 - $24,000 $24,001 - $27,000 $27,001 - $30,000 $30,001 - $33,000

    $33,001 36,000 $36,001 - $39,000 $39,001 - $42,000 OVER $42,000

    SOURCE OF INCOME A:

    EMPLOYMENT SOCIAL SERVICES/SFI STUDENT FINANCE

    EMPLOYMENT INSURANCE CHILD SUPPORT IMMIGRATION CANADA

    AISH/DISABILITY CANADA PENSION PLAN WCB

    SOURCE OF INCOME B:

    EMPLOYMENT SOCIAL SERVICES/SFI STUDENT FINANCE

    EMPLOYMENT INSURANCE CHILD SUPPORT IMMIGRATION CANADA

    WCB AISH/DISABILITY CANADA PENSION PLAN

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    c/o the amiskwaciy Cultural Society (Revised May 2017) Page 4

    Does your current income meet the financial needs of your family? YES NO

    Which needs are not being met?

    _______________________________________________________________

    _______________________________________________________________

    How is this affecting your family?

    _______________________________________________________________

    _______________________________________________________________

    What is the education level of the primary caregiver of the child?

    Grade ________

    Technical training: Area of study: _____________________________

    College or university: Area of study:_____________________________

    Other ________________________________________________________

    Age of the primary Parent/Caregiver?

    Under 20 years old 30-40 years old

    20-30 years old Over 40 years old

    Type of family? Single parent Two parent Foster parent Other_______

    Grandparents Kinship care Group home

    Residents in the home?

    Mother (bio) Step-Mother Father (bio) Step-Father Childs grandmother

    Childs grandfather Childs Uncle Childs Aunt

    Childs siblings & number of siblings______________ Childs Cousin(s) Family Friend(s) Other________

    Names and Ages of Siblings:

    Name: __________________________________ Age: ____________

    Name: __________________________________ Age: ____________

    Name: __________________________________ Age: ____________

    Name: __________________________________ Age: ____________

    Name: __________________________________ Age: ____________

  • 5

    c/o the amiskwaciy Cultural Society (Revised May 2017) Page 5

    HEALTH INFORMATION

    Does your child have any special needs that we should know about? (Special diet,

    language problems, particular fears etc.) Yes No

    _________________________________________________________________

    _________________________________________________________________

    Has your child had previous assessments (speech& language, OT) Yes No

    _________________________________________________________________

    _________________________________________________________________

    What family issues should we be aware of that have been occurring in the home

    and affecting your child?

    _________________________________________________________________

    _________________________________________________________________

    Does your child have a family doctor? Yes No, we go to a Medicentre

    Childs Doctor: ___________________ Type: Family Pediatrician Specialist (ears, nose, throat)

    ___________________

    Doctors Address: _____________________ Phone: ____________________

    Medicentre: ___________________________ Phone: ____________________

    Alberta Health Care Number: _______________________________________ Birth Certificate Number: __________________________________________

    Treaty Number: __________________________________________________

    Is childs immunization up to date?