Applications

Fillable Application Packets
CC EHS Application Packet 22/23 HS & GSRP Application Packet 22/23 HS Recertification Packet 22/23

Application Training Materials

Income and Eligibility Training PowerPoint

Income and Eligibility Training Refresher PowerPoint 2022

Online Pre-Application

Staff responsible for taking applications will regularly check the pre-application sheet in Google Sheets to check for families interested in the program they work with. Staff will try to connect with families 3 times by phone call and text. If there is no response, staff will mail the Pre-App Follow Up Letter for Families and send out an email to try to make contact. If there is still no response from the family after these attempts, staff will move the family information to the "No Response Pre-App CC and EHS Center Based" tab.
Refer to the Maintaining Online Pre-App Guidance (2/22) for more information.

Link to Pre-App that can be shared with families: https://docs.google.com/forms/d/e/1FAIpQLSeBRREv0bE2pfFNxKmx3WFjuEigbD5caRuY4BvAYpTA5C-lLg/viewform?usp=pp_url

Pre-App QR Code:

Before and After Lists for Parents

Mail full size- In Person Appointment Reminder for Families 2022
Post Card- In Person Appointment Reminder for Families 2022
Mail full size -Phone Appointment Reminder for Families 2022
Post Card- Phone Appointment Reminder for Families 2022
Completion Memo 2021

Eligibility Verification Page

EHS Verification 1/21
HS Verification 1/21

Intake Forms

Adobe Form Save-Save As Procedure 1/21
Docusign Procedure 10/21
Instructions for Completing the Client Intake 1/22
HS/EHS Application Pg.1 & 2

Customer Connections Form
22/23 Child Plus Data Entry Codes
21/22 Calendar
22/23 Age Eligibility Chart

Family Income

Third Party Documentation 2021
Family Income Statement 2021
Child Development Poverty Guideline 2022

Families In Transition

Attach a copy of the Disclosure With Parental Consent form to the Families in Transition Questionnaire when submitting to the McKinney Vento Liaison.
Families in Transition Questionnaire
McKinney Vento Liaison List 19/20
McKinney Vento Flow Chart

Health and Dental Forms and Releases

Medical/Dental Homes Guidance
While it is important to collect a fair amount of information and forms at time of application to identify eligibility, it is also important to begin the process of identifying needs with families. One piece in identifying needs is to consult with parents to determine whether each child has ongoing sources of continuous, accessible health care – provided by a health care professional that maintains the child’s ongoing health record and is not primarily a source of emergency or urgent care (HSPPS 1302.42). This includes both medical and dental homes.
Please see the following for how to enter this information accurately on the application and for CP entry.

Dental and medical homes are only written on the application if the child has been seen by the dental or health clinic.
If the dental and/or medical home is listed on the application, DMT will mark “yes” at enrollment for this child.
If there is not a medical or dental home listed on the application “no” will remain on CP (PIR) “At Enrollment”.
When an FSS or CCSC receive a WBC appointment date or dental appointment date for a child that did not have a medical home/dental home on their application, they must change CP (PIR) to Yes (At End Of Enrollment) because they found a medical/dental home while working in our program.
If the FSS or CCSC sends for documentation of the appointment and it is found that the child was never registered as a client at the medical or dental home, staff must change CP (PIR) to No (At Enrollment) and No (At End of Enrollment). If staff gets a completed dental or WBC, Yes would be documented (At End of Enrollment)
When staff enrolls a family, they will confirm the dental and medical home information is correct. If the medical/dental home information has changed since the time of application, the “At Enrollment” information in CP should be updated so this is correct.

Health Forms and Releases

EHS Child Health History
HS Child Health History

Release of Health Information 1/21
Release of Oral Health Information 1/21

EHS Child Development and Care Subsidy

EHS CDC Guidance

EHS CDC Documentation 1/21

Link to the Child Development and Care handbook

Recertification
A recertification is used when a child was enrolled for the 2021-2022 school year as an eligible child, and the family intends for the child to return to a Head Start program. Children who were enrolled as 101-130% or over-income, children transitioning to a GSRP classroom, and children entering their 3rd year of HS will need new applications for the upcoming school year.

Recertification Packet 22/23