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2018-19 Head Start Application
The Denton ISD Head Start program is a federal full day program that is housed at Ann Windle School for Young Children.
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Email
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Your email
CHILD DEMOGRAPHICS
Child First Name
Your answer
Child Last Name
Your answer
Child's Gender
Sexo del niño/a
Choose
Female/femenino
Male/masculino
Child's Birthdate
MM
/
DD
/
YYYY
Child's Living Address
Dirección donde vive el/la niño/a
Your answer
Is the mailing address the same?
Recibe su correo en esta misma dirección?
Choose
yes
no
If not, please enter the mailing address
Si no, por favor escriba la dirección donde recibe su correo.
Your answer
Child's Ethnicity
Etnicidad del niño/a
Hispanic/Latino
Not Hispanic/Latino
Child's Race
Etnicidad del niño/a
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Child is currently enrolled..
Niño/a está inscrito/a actualmente.
Choose
Ann Windle School
Borman Elementary
Cross Oaks Elementary
Gonzalez School for Young Children
Lee Elementary
Newton Rayzor Elementary
Rivera Elementary
Ryan Elementary
Stephens Elementary
Not enrolled in Denton ISD
Child Care Provided by
Quién cuida al niño?
Older sibling under 12
Older sibling 13 or older
A relative
Child Care Center (daycare)
Adult non-relative in child's home
Adult non-relative not in child's home
Need to locate a provider
Name of childcare/daycare (if applicable)
Nombre de la guardería (si aplica)
Your answer
PRIMARY AND SECONDARY CAREGIVER INFORMATION
Number of adults living in household
Número de adultos que viven en la casa
Choose
5
4
3
2
1
Mother/Father Figure's Name
Nombre de la persona que está mayormente a cargo del niño/a
Your answer
Mother/Father Figure's Gender
Sexo de la persona que está mayormente a cargo del niño/a
Choose
Female
Male
Mother/Father Figure's Ethnicity
Raza/etnicidad de la persona que está mayormente a cargo del cuidado del niño/a
Hispanic/Latino
Not Hispanic/Latino
Other:
Mother/Father Figure's Race
Raza/etnicidad de la persona que está mayormente a cargo del cuidado del niño/a
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian/Other Pacific Islander
White
Other:
Days and Hours Worked
Días y horarios trabajados
Sundays
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
6am - 2pm
7am- 4pm
8am -5pm
2pm-10 pm
10pm-6am
Not Employed
Other:
Cell Phone
Número de teléfono celular
Your answer
Mother/Father Figure's Email Address
Dirección de correo electrónico
Your answer
Preferred Method of Communication?
Dirección de correo electrónico
Choose
Cell Phone
Work Phone
Home Phone
Email
USPS Mail
Secondary Caregiver's Name
Nombre del cuidador secundario
Your answer
Gender
Sexo
Choose
Female
Male
Secondary Caregiver's Ethnicity
Choose
Latino/Hispanic
Not Latino/Hispanic
Secondary Caregiver's Race
Raza/etnicidad del cuidador secundario del niño/a
American Indian/Alaska Native Asian
Black/African American
White/Caucasian
Hawaiian or other Pacific Islander
Hispanic/Latino
Other:
Days and Hours Worked
Días y horario trabajados
Sundays
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
6am - 2pm
7am- 4pm
8am -5pm
2pm-10 pm
10pm-6am
Not Employed
Other:
Phone Number
Teléfono
Your answer
Email Address
Dirección de correo electrónico
Your answer
Family Size
Tamaño de la familia
Choose
2
3
4
5
6
7
8
9
10
Number of children in household
Nümero de niños en la casa
Choose
1
2
3
4
5
6
7
8
9
10
Full Name & birthdate of first child
Nombre, apellido y fecha de nacimiento del primer niño/a
Your answer
Full Name & birthdate of second child
Nombre, apellido y fecha de nacimiento del segundo niño/a
Your answer
Full Name & birthdate of third child
Nombre, apellido y fecha de nacimiento del tercer niño/a
Your answer
Full Name & birthdate of fourth child
Nombre, apellido y fecha de nacimiento del cuarto niño/a
Your answer
FAMILY NEEDS ASSESSMENTS & INTERESTS SURVEY
Read each section to help determine your family needs.
Education Needs
Educación
GED/Equivalencia de la preparatoria
ESL
Vocational
College/Universidad
Language/Idioma
Literacy/Alfabetismo
Health Care/Cuidado de salud
Discipline
Assisting child with schoolwork/Ayudando al niño/a con sus tareas escolares
Parent volunteering in the classroom
Parent volunteering in school wide activities
Workshops on job training and resume's
Computer and technology workshops
NA
Other:
Clear selection
Health Services Needs
Servicios de salud
Mental Health/Salud mental
Disability/Discapacidad
Health/Salud
Immunization/Vacunas
Diabetes
Heart/BP/Corazón/Presión arterial
Children's Health/Salud de los niños
Dental Health/Salud dental
Parent health and nutrition classes
Help with finding a dental and medical home
Other:
Clear selection
Housing Needs
Vivienda
Rent/Alquiler o renta
Utilities/Servicios públicos
Furniture/Muebles
Section 8
Shelter/Emergency/Albergue/Emergencia
Workshops on budgeting and banking/saving
Other:
Clear selection
Other Needs
Otras necesidades
Clothing/Ropa
Transportation
Child Care/Cuidado de los niños
Immigration
Amnesty/Amnistía
Elder Care/Cuidado de ancianos
Workshops of love and family relationships
Workshops on immigration
Other:
Clear selection
Financial Assistance Needs
Ayuda financiera
Banking/Budgeting/Uso del banco/Presupuesto
Credit Counseling/Consejería para créditos
SSI
TANF
Financial training and workshops
Other:
Clear selection
Nutrition Needs
Nutrición
WIC Information
Nutrition Classes
Other:
Clear selection
Employment Needs
Empleo
Job Placement/Ayuda para conseguir trabajoa
Job Training/Entrenamiento para empleo
Other:
Clear selection
Counseling Needs
Consejería
Child Behavior Management/Manejo del comportamiento del niño/a
Child Abuse/Neglect/Abuso infantil/Abandono
Family Counseling/Consejería familiar
Divorce/Separation
Parenting Classes/Clases para padres
Substance Abuse
Death/Muerte
Other:
Clear selection
Crisis Condition
Condición de crisis
Homeless
Foster Care
Domestic Violence
Severe health concerns
Clear selection
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