ECSE/WALK IN/HEADSTART ENROLLMENT
All information must be completed - for use with ALL ECSE STUDENTS & WALK IN/HEAD START SPEECH Students NOT IN PFA -- Any ISP student
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Legal name of student (First, Middle, Last) *
Student's date of birth *
MM
/
DD
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YYYY
Gender of student *
Ethnicity of student *
IEP or ISP *
Entry type of student: *
Type of classroom/ services *
Enrollment date (date services are to begin) *
MM
/
DD
/
YYYY
Home School of student - where would he/she go if non IEP? *
Serving School of student - where will the student receive services? For walk in students, home and serving should be the same *
SIS # of student (if you do not have it, please list zero) *
Is the child's native language English? *
Is the student homeless per ISBE criteria? *
PREVIOUS ENROLLMENT IN AN EARLY CHILDHOOD PROGRAM- Has the child ever been in PreK, ECSE, or HeadStart? *
Did the child receive Early Head Start services? (birth - 3) *
Did the child participate in Prevention Initiative (Birth to 3)? *
Did the child receive Early Intervention services? (Birth to 3) *
Please list the child's EI number, if applicable.
Was there a delay in transition from EI? *
Does the child currently attend HEAD START? *
Previous CHILD WELFARE involvement (DCFS, Foster Care, Family Services) *
Is the child currently in foster care or at any time in the past year lived in a foster care setting? *
Has the family been assigned a DCFS caseworker and is currently receiving services or has in the past year *
Is either parent of the child currently or at any time in the past year been a ward of the state (incarcerated)? *
Does the child's parent have military involvement? *
RECEIVING TANF *
RECEIVING WIC *
RECEIVING SNAP *
RECEIVING HOUSING SUBSIDY *
FAMILY STRUCTURE *
Household Income: Number of household members *
Household Income: Annual household income: *
Emergency Contact #1 -- Name of Person *
Emergency Contact #1 PHONE NUMBER *
Emergency Contact #2 - Name of Person *
Emergency Contact #2 PHONE NUMBER *
Email address of staff member completing this form (for questions) *
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