LCCAA Quick Application

Student Information

Application Type: New Applicant Sibling Applicant (select if a sibling in the household is currently enrolled in the program)

Sibling Name:

Child:

Date of Birth:

Gender: Male Female

School District of Residence:

Disability Status: No Disability
Diagnosed but no IEP or IFSP
Diagnosed with IEP or IFSP
Suspected but not diagnosed

Is your Child Potty Trained?
Yes No

Does your child wear a pull-up?
Yes No

When does your child wear pull ups?
All Day At Bedtime N/A my child wears underwear

Does your child have any food allergies or restrictions?
Yes No
Please explain:

Household Information

Total number of adults in household:

Note: if this child is a dual-custody child, enter the number of adults in both households combined

Total number of children in household:

Note: if this child is a dual-custody child, enter the number of children in both households combined

Guardian #

First Name:

Last Name:

Gender: Male Female

Does this person count in the income eligibility calculations?: Yes No

Role in household: Father-figure Mother-figure Other

Other Role:

Relation to child: Biological Mother Biological Father Other

Other Relation:

Employment Status: Employed Full Time
Employed Part Time
Employed Seasonal
Unemployed
Retired
Disabled

Enrolled in School Or Training: Yes, Full-Time Yes, Part-Time No

Education Level: Less than high school
High school graduate or GED
Associate Degree, vocational school, or some college
Advanced degree of baccalaureate degree

Reside in house: Yes No

Address:

City, State Zip: ,

Phone(s):

Email Address:

Primary language spoken in the home: English Spanish Other

Other Language:

Does Parent need an Interpreter: Yes No

Guardian #

First Name:

Last Name:

Gender: Male Female

Does this person count in the income eligibility calculations?: Yes No

Role in household: Father-figure Mother-figure Other

Other Role:

Relation to child: Biological Mother Biological Father Other

Other Relation:

Employment Status: Employed Full Time
Employed Part Time
Employed Seasonal
Unemployed
Retired
Disabled

Enrolled in School Or Training: Yes, Full-Time Yes, Part-Time No

Education Level: Less than high school
High school graduate or GED
Associate Degree, vocational school, or some college
Advanced degree of baccalaureate degree

Reside in house: Yes No

Address:

City, State Zip: ,

Phone(s):

Email Address:

Primary language spoken in the home: English Spanish Other

Other Language:

Does Parent need an Interpreter: Yes No

How did you hear about the program?:

Email
Phone
Center
Website
Event
Referral
Other

Other Source:

Preferences

Program Type: Head Start

Program Option Preferences: Full Day
Half Day AM
Half Day PM
Home Based

Center Preference:
(Directly Operated)
Hopkins-Locke (Lorain)
Griswold (Elyria)
Central Plaza (Lorain)
Wellington
Firelands
LaGrange
107 Oberlin Rd (South Elyria)

(Collaborative Partners)
Horizon
Little Lighthouse Learning

Home Based

Family Income

Special Eligibility Information: Someone in family receives cash benefits or other services through TANF or SNAP
Someone in family receives public assistance through SSI (not SSD or Veterans Benefits)
Family is homeless
Child is foster child

Is this child a dual-custody child?: Yes No