GREATER ERIE COMMUNITY ACTION COMMITTEE

18 WEST NINTH STREET

ERIE, PA  16501

(814) 459-4581 or 1-800-769-2436

                                                                                                                                                                                               

Click in each text box and type your information by using the space bar or mouse to navigate to the next piece of information on the same line.  SAVE completed application and Email to lbryant@gecac.org using HS Application as the Subject Line OR print application, fill out and mail to above address. Please answer all questions fully or call 459-4581, ask for Head Start and your application will be taken over the phone.

I am applying for (Choose one)          Choice:    Today’s Date

 

HEAD START   A) Part Day Program (September-May)    

 B) Full Day/Full Year (Childcare hours before and after Head Start hours provided, for parents in school and/or working, fees involved)

 C) Home Base Program (September-May)                   

Child’s Name  Birth DateCell #

 

Parent’s Names  Phone #

Address  City Zip

If child will be picked up and dropped off at a different address than the home address list:

Address  E-Mail:

Directions (if outside of City)

Head Start is a Family Oriented Program.  As parents you will have the opportunity to take part in its many activities, ranging from volunteering in the classrooms to serving on parent committees.

When your application is received, you will be notified by mail of the status of your application.  When your child is selected for enrollment, a Case Manager will contact you to make an appointment to begin the enrollment process.

Head Start does require every child enrolled in the program to have a physical and dental examination.  The Case Manager will help you get this completed.  Your child’s immunizations must also be up to date.  Check with your physician to make sure immunization records are complete. 

HOUSEHOLD INFORMATION:  Are you an American citizen?      YES                NO

Number of children (under 18)                    Ages: Number of Adults  Relationship to Child (Check All that apply)                             

Father   Mother    Grandfather Grandmother Uncle Aunt Brother Sister Friend Guardian Foster Parent

Source of Income (Choose all that apply) Employment Public Assistance  SSI UnemploymentChild Support Social Security Other

Amount of Income                (Choose One) Weekly Biweekly  Monthly Yearly

Why do you wish to enroll your child in Head Start?

Highest level of education you have completed   /If not high school/GED, may we give your information to Adult Education / Even Start Program? YesNo

Have you had a child in Head Start Before? YesNoIf so, when?

How did you hear about the GECAC Head Start program?