This document contains an application for migrant and seasonal Head Start services. It collects information from the primary and secondary caregivers, including demographics, income sources, housing status, and languages spoken. Information is also collected for each eligible child, including languages, disabilities, and child care needs. Applicants sign to confirm the truth and accuracy of the information provided and acknowledge it is subject to verification.

1. Enrollment Year________ Center ID # __________
TELAMON CORPORATION
MIGRANT & SEASONAL HEAD START APPLICATION
Complete one copy per family
PRIMARY CAREGIVER INFORMATION
1. First Name_________________________ M. Initial:_____ Last Name_____________________________________
2. Gender: __________ 3. *Application Date: ________________ 4. *Date of Birth:____________________________
5. TANF #__________________________ 6. *Receiving WIC:  Yes  No  Previously
7. *Which language do you speak (primary)?
 English  Spanish  Native Central or South American/Mexican
 Caribbean  Pacific Island  Native North American or Alaska Native
 European/Slavic  African  Middle Eastern/South Asian
 East Asian  Unspecified  Other (Specify):______________________________
8. *Which language do you speak (secondary)? (Choose from above list and write in here)________________________
9. *Ethnicity:  Hispanic  Non-Hispanic
10. *Race:
 American Indian or Alaska Native  Asian  Black or African American
 Native Hawaiian/Pacific Islander  White  Bi-Racial/Multi-Racial
 Unspecified  Other (Specify):_____________________________________
11. *What is your highest level of education?
 Less than high shool graduate  High School Graduate/GED
Some college, vocational school or Associate degree  Bachelor or advanced degree
12. *What is your employment status?
 Employed  In job training or school
 Not working  Both working and in training/school
13. What is your employer’s or school’s name:__________________________________________________________
14. What are your phone numbers? Home:___________________________________________________________
Mobile:_________________________________________ Work:____________________________________
15. What is your local address?
StreetAddress:_____________________________________________________________________________
City:______________________________ State:________Zip Code:_____________County:______________
16. What is your mailing address (if different from above) (note: data entry as “other”):
StreetAddress:_____________________________________________________________________________
City:______________________________ State:________Zip Code:_____________
17. *Number in family: _______Adults _________Children __________ Total
18. *Number in household __________
19. Are you disabled?  Yes  No
20. *Do you have medical insurance?  Yes  No If yes, specify type:
____________________________________
21. Are you pregnant?  Yes  No If yes, specify due date: ______________________________________

2. Enrollment Year________ Center ID # __________
Family Name________________________________
22. *What is your current housing?  Homeless  Own  Rent  Other_______________________________
*Date you began living in your current housing?__________________________________________________
23. *What was your previous housing?  Homeless  Own Rent  Other_______________________________
24. Have you and your family moved in the last 24 months?  Yes  No
25. What type of housing are you currently in?
 Apartment  House  Duplex  Mobile Home  Other____________________
26. What is the cost for your current housing? $_____________________
27. Family Type:  Single Parent/Female  Single Parent/Male  Two Parent  Other________________
28. Do you receive:  HEAP  Food Stamps
SECONDARY CAREGIVER INFORMATION
 No secondary caregiver (skip to income information section)
1. First Name_________________________ M. Initial:_____ Last Name_____________________________________
2. Gender: __________ 3. *Application Date: ___________________ 4. *Date of Birth:________________________
5. TANF #_________________________ 6. *Receiving WIC:  Yes  No  Previously
7. *Which language do you speak (primary)?
 English  Spanish  Native Central or South American/Mexican
 Caribbean  Pacific Island  Native North American or Alaska Native
 European/Slavic  African  Middle Eastern/South Asian
 East Asian  Unspecified  Other (Specify):______________________________
8. *Which language do you speak (secondary)? (Choose from above list and write in here)________________________
9. *Ethnicity:  Hispanic  Non-Hispanic
10. *Race:
 American Indian or Alaska Native  Asian  Black or African American
 Native Hawaiian/Pacific Islander  White  Bi-Racial/Multi-Racial
 Unspecified  Other (Specify):_____________________________________
11. *What is your highest level of education?
 Less than high shool graduate  High School Graduate/GED
Some college, vocational school or Associate degree  Bachelor or advanced degree
12. *What is your employment status?
 Employed  In job training or school
 Not working  Both working and in training/school
13. What is your employer’s or school’s name:__________________________________________________________
14. What are your phone numbers? Home:_______________________________________________________
Mobile:________________________________________ Work:_____________________________________
15. What is your local address?
StreetAddress:_____________________________________________________________________________
City:___________________________ State:_________Zip Code:_____________County:________________
16. What is your mailing address (if different from above) (note: data entry as “other”):
StreetAddress:_____________________________________________________________________________
City:___________________________ State:_________Zip Code:_____________

3. Enrollment Year________ Center ID # __________
Family Name________________________________
17. *Number in family: _______Adults _________Children __________ Total
18. *Number in household __________
19. Are you disabled?  Yes  No
20. *Do you have medical insurance?  Yes  No If yes, specify type:
__________________________________
21. Are you pregnant?  Yes  No If yes, specify due date: ______________________________________

4. Enrollment Year________ Center ID # __________
Family Name________________________________
CAREGIVER INCOME INFORMATION
(Transfer summary information from income work history)
Income Primary Caregiver Secondary Caregiver
Employment $ /Year $ /Year
Child Support $ /Year $ /Year
SSI $ /Year $ /Year
TANF $ /Year $ /Year
Unemployment $ /Year $ /Year
College Grants & Scholarships $ /Year $ /Year
Social Security $ /Year $ /Year
Other ____________ $ /Year $ /Year
 No Income  Receives SSI  Receives TANF
Income Comments:
1. Is the family’s Primary Income Source agricultural work (based on last 12months’ income)? /
Yes (Skip to # 3) No (Go to # 2)
2. Does the First-Time Migrant Worksheet show that the family has verified first-time migrant status?
N/A
Yes (include the Worksheet behind this application in the family’s file).
No (Family is Ineligible for services – End of Intake)
3. Is the family currently working in agriculture? Yes (skip to #5) No (go to #4)
4. If the family is not currently working in agriculture, do they plan to work in agriculture while their
child(ren) are enrolled in MSHS?
Yes If yes, when and for whom? ___________________________________________________
NOTE: They must provide evidence of current work in agriculture once they start working.
No (Family is Ineligible for services – End of Intake)
5. Did the family move within the last 2 years for the purpose of seeking agricultural employment
Yes, specify type of move Interstate Intrastate
_____Number of moves for purpose of agricultural work within the past 24 months
First-Time Migrant (Must verify low-income for 52 weeks)
No (end of intake for MI)
No, however family qualifies as Seasonal Farm Worker (TN only)

5. Enrollment Year________ Center ID # __________
Family Name________________________________
CHILD APPLICATION
(Complete one for each age eligible child in family along with a Priority Point Sheet)
1. First Name_____________________ M. Initial:_____ Last Name_________________________
2. Gender: __________ 3.*Application Date: _____________ 4. *Date of Birth:_________________
7. *Which language does your child speak (primary)?  Not yet speaking
 English  Spanish  Native Central or South American/Mexican
 Caribbean  Pacific Island  Native North American or Alaska Native
 European/Slavic  African  Middle Eastern/South Asian
 East Asian  Unspecified  Other (Specify):______________________
8. *Which language does your child speak (secondary)? (choose from above list and write in here)________
9. Is English spoken at home?  Yes  No
10. How would you rate your child’s English skills?  Very Well  Well  Not Well  Not at all
9. *Child’s Ethnicity:  Hispanic  Non-Hispanic
10. *Child’s Race:
 American Indian or Alaska Native  Asian  Black or African American
 Native Hawaiian/Pacific Islander  White  Bi-Racial/Multi-Racial
 Unspecified  Other (Specify):_______________________
11. *Does your child have a disability?  Yes  No
If yes:
 Disability evaluation in progress  IEP/IFSP
 Other (Specify):_______________________________________________
12. How many years has your child been enrolled in this Migrant Head Start program?___________
13. *This child needs:
 Full time child care  Part time child care  Evening child care
 Overnight child care  Weekend child care
 *Child is receiving a child care subsidy/voucher
*Secondary source of child care (outside of Head Start):
 Family child care home
 Child care center (other than Head Start)
 At home or at another home with a relative or unrelated adult
 Public school pre-kindergarten program
 Other(specify):__________________________________________________________
14. *Did this child receive services before classes began this season?  Yes  No
15. *Child’s father/father figure participates in regularly scheduled program activities  Yes  No
16. Child has a medical card:  Yes  No

6. Enrollment Year________ Center ID # __________
Family Name________________________________
FAMILY USER DEFINED QUESTIONS:
1. Does this family need a translator?  Yes  No
2. List name/age/gender of other siblings in family:
Name _______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
Name _______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
3. What is the family’s “home based” address and phone number:
Address_________________________________________________________________________________
City_______________________________________ State_________________ Zip Code_______________
Phone number:______________________________________________ County:______________________
The information provided here is true to the best of my knowledge. I understand that this information is
subject to review and verification and that this includes providing documents or employer confirmation to
support it. I further understand that my child(ren) may be terminated from the program if found ineligible. I
have read and understood the above or had it explained to me. I have been advised about Telamon’s
eligibility and the program’s complaint procedures.
Según mi leal pensar y saber la información proveída está correcta. Entiendo que esta información estará
sujeta a revisión y verificación y me doy cuenta de que me pueden pedir que yo provea la verificación para
apoyar estos datos. Yo entiendo que mi/s niño/s pueden ser descalificados inmediatamente si no me
encuentran eligible. Yo he leído y entendido todo lo anteriormente citado, o me lo han explicado. También
me han explicado la política de Telamon sobre la elegibilidad de familias para Head Start y el
procedimiento de quejas y apelaciones.
Parent Signature: _____________________________________________ Date:______/_______/______
Staff Signature:_______________________________________________ Date:_____/_______/_______

7. Enrollment Year________ Center ID # __________
Family Name________________________________
FAMILY USER DEFINED QUESTIONS:
1. Does this family need a translator?  Yes  No
2. List name/age/gender of other siblings in family:
Name _______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
Name _______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
Name ______________ AGE ______ Male Female
3. What is the family’s “home based” address and phone number:
Address_________________________________________________________________________________
City_______________________________________ State_________________ Zip Code_______________
Phone number:______________________________________________ County:______________________
The information provided here is true to the best of my knowledge. I understand that this information is
subject to review and verification and that this includes providing documents or employer confirmation to
support it. I further understand that my child(ren) may be terminated from the program if found ineligible. I
have read and understood the above or had it explained to me. I have been advised about Telamon’s
eligibility and the program’s complaint procedures.
Según mi leal pensar y saber la información proveída está correcta. Entiendo que esta información estará
sujeta a revisión y verificación y me doy cuenta de que me pueden pedir que yo provea la verificación para
apoyar estos datos. Yo entiendo que mi/s niño/s pueden ser descalificados inmediatamente si no me
encuentran eligible. Yo he leído y entendido todo lo anteriormente citado, o me lo han explicado. También
me han explicado la política de Telamon sobre la elegibilidad de familias para Head Start y el
procedimiento de quejas y apelaciones.
Parent Signature: _____________________________________________ Date:______/_______/______
Staff Signature:_______________________________________________ Date:_____/_______/_______