Head Start 2025-2026

Name #1

NameRelationship to ChildDate of Birth

Name # 2

NameRelationship to ChildDate of Birth

Name # 3

NameRelationship to ChildDate of Birth

Name # 4

NameRelationship to ChildDate of Birth

Name # 5

NameRelationship to ChildDate of Birth

Name # 1

NameRelationship to ChildDate of Birth

Name # 2

NameRelationship to ChildDate of Birth

Name # 3

NameRelationship to ChildDate of Birth

Name # 4

NameRelationship to ChildDate of Birth

Name # 5

NameRelationship to ChildDate of Birth

Address

Street Address

County

CityState / Province

Postal / Zip Code

Phone Number #1

Please enter a valid phone number.

Type

CellHomeWorkOther

Best time to call?

#1 Opt in for Text messages?

YesNo

Phone Number #2

Please enter a valid phone number.

Type

CellHomeWorkOther

Best time to call?

#2 Opt in for Text messages?

YesNo

Phone Number #3

Please enter a valid phone number.

Type

CellHomeWorkOther

Best time to call?

#3 Opt in for text messages?

YesNo

Parental Status

OneTwo

Primary Language at home?

Family Homeless?

YesNo

Active Duty/Military?

YesNo

Military/Veteran?

YesNo

Referred to Child Welfare Agency?

YesNo

Receiving SNAP?

YesNo

WIC ?

YesNo

Does your child have a disability (diagnosed by a doctor or specialist)?

YesNo

Does your child have an IEP/IFSSP?

YesNo

Do you have any concerns about your child in any of the areas listed?

Please describe if other developmental concerns

Please describe, if emotional/behavioral problems

Please describe if other medical problems

Is your family currently dealing with legal issues such as divorce, probation, etc?

YesNo

Do you currently have any custody orders or joint custody?

YesNo

If, Yes please explain

Name & Relationship #1

Phone Number

Please enter a valid phone number.

Type

CellularHomeWorkOther

Address # 1

Name & Relationship #2

Phone Number

Please enter a valid phone number.

Type

CellularHomeWorkOther

Address # 2

Name & Relationship #3

Phone Number

Please enter a valid phone number.

Type # 3

CellularHomeWorkOther

Address

Is there a court order in place that restricts anyone from picking up your child?(non-custodial parent or other adult due to restraining order, child's foster or kinship status etc.) If yes, please provide MELA with documentation, such as a copy of a court order to maintain in file and provide updates as needed.

YesNo

Name # 1 (If yes, please list name)

First NameLast Name

Name #2 (If yes, please list name)

First NameLast Name

Parent/Guardian Signature*

Date

1. Is your family currently homeless? (doubled up with others because you cannot afford housing; in a motel, shelter, or abandoned building; on the streets; or in a car , or child is living with a caregiver who is not the legal guardian)

YesNo

2. Is the child in a state approved foster care placement? If Yes, please bring in proof of foster placement. Go to #7

YesNo

3. Does your family receive SSI? (Supplemental Security Income) If Yes, bring in current proof of SSI at intake process.

YesNo

4. Does your family receive TANF (Temporary Assistance to Needy Families) bring in current proof of TANF to intake.

YesNo

5. If your family has had earned income this year, what is your estimated Gross Annual Income?

5. Please mark the documentation that you will bring in with you to intake. All income must be reported for all parent/Guardian's who are living with the child. If you had no income for the past 12 months or last calendar year, go to #6

Please upload income documents ( 1 month of paystubs, W-2)

If you had no income for the past 12 months, a form will be provided at intake, please bring names and contact information of individuals that can attest to this statement and be prepared to explain how you and your child were supported for each of the last twelve months.

Sign and date to indicate that you declare the above information to be true and correct. We will review this information at the intake appointment.

Name of Parent/Guardian

First NameLast Name

Signature*

Date

Applicants, please upload photo of Tribal ID, birth certificate, child insurance card, state immunization registry for proof of age.

File Upload

Child's Name #1

First NameLast Name

Child's Name #2

First NameLast Name

Child's Name #3

First NameLast Name

Date of Birth # 1

Date

Date of Birth # 2

Date

Date of Birth # 3

Date

As a parent/guardian of the child named above, I hereby grant

Muckleshoot Indian Tribe Head Start ProgramMuckleshoot Indian Tribe CCDF ProgramMuckleshoot Indian Tribe Birth to Three ProgramMuckleshoot Indian Tribe Child Development Center

To request information relevant to my child/family from:

Including any or all of the following (as checked below):

Child Health information (well-child, dental Exam, Immunizations,lead/hemoglobin/Hematocrit test results)Family eligibility information, including current family status/or employment/income verificationChild's Birth CertificateChild's Tribal StatusChild Developmental/educational information (assessments, progress reports)Family Services information (needs assessment, service plan)Other Please specifyInformation regarding child's special needs (observations, individual education plan) if applicableOther

I understand that the confidentiality of any information identifying my child and/or myself will be maintained in accordance with the law and both federal and state regulations. Such information will only be used with my consent for the benefit of my child or me.

By signing below, I also acknowledge that:

I may review the indicated information at any time

This authorization is voluntary, and I may refuse to sign it. My refusal to sign will not affect my eligibility for services or enrollment.

This authorization will expire two (2) year's from the date below, but I may also choose to revoke it any time.

Parent/Guardian Name

First NameLast Name

Address

Street Address

CityState / Province

Postal / Zip Code

Parent/Guardian Signature*

Date

Head Start 2025-2026

Parent Guardian Information #1

Additional Members (who live with the family and ARE supported by Parent/Guardian's Income

Additional members (who live with family and ARE not supported by Parent/Guardian's Income

Family Information - Income & Contacts

Child's Needs

Emergency Contacts

Family Income Worksheet/ Head Start Program

Muckleshoot Indian Tribe Permission to Release/Request Information