Placer Community Action Council, Inc.

1166 High Street Auburn, Ca 95603

Phone: (530) 885-5437 or 1(800) 655-0432
Fax: (530) 885-1902 Web: www.KidZKount.com
Dear Parent/Guardian:
Thank you for your interest in the KidZKounts Early Head Start, Head Start, and
State Preschool programs.
Please fill out the attached application completely, and return it to us as soon as
possible. Your application must be fully complete and include the required
documentation before your child can be considered eligible for our program.
Head Start, State preschool, and Early Head Start are federal and state funded
programs that are FREE for qualifying families.
Head Start and State Preschool serves children ages 3 and 4, with priority given
to children who will be 4 years old by October 1st for the current school year.
Service options (determined by location) include: center-base, child care, and
family child care homes.
Early Head Start serves children prenatal to 3 years old. Service options
(determined by location) include: center-base, home-base, and family child care
homes.
The childrens program provides a supportive climate of learning for your child
under Child Development, Health, Nutrition, Parent Involvement, Family
Services, Disabilities, and Mental Health.
If you have further questions, or need help in filling out your application, please
feel free to call (530) 886-4122 or 1(800) 655-0432.
KidZKount has a variety of locations throughout Placer and Nevada Counties.

OUR MISSION IS TO EMPOWER CHILDREN AND THEIR FAMILIES TO MAXIMIZE

THEIR FULL POTENTIAL THROUGH OPPORTUNITIES FOR GROWTH AND CHANGE
FUNDED BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
License # 313602274

Placer Community Action Council, Inc.

1166 High Street Auburn, Ca 95603
Phone: (530)885-5437 or 1(800)655-0432
Fax: (530)885-1902 Web: www.KidZKount.com

Required Documentation Checklist

Required Documentation - In order to process your application, copies of
the following information must be attached:
[]

Childs Official Birth Certificate

[]

Familys Income Documentation (A full month of income documentation

is required)

[]

Childs Official immunization Record (Age appropriate vaccines must

be current)

[]

Childs Current Physical Exam Record Including Tuberculosis

Assessment and a Blood Lead Test

[]

Childs Dental Exam Record (Preschool age children must have a dental
exam within 12 months of their application)

Other Documentation Requested In order to best meet the needs of your

family, and insure all necessary modifications and support services are in
place prior to your child attending the program, a copy of the following is
required prior to enrollment, if applicable:
[]

Individual Education Plan (IEP)

[]

Individual Family Service Plan (IFSP)

Thank you for your interest in KidZKount programs! If you have any questions or
need assistance, please call us at (530)886-4122 or 1(800)655-0432.

License # 313602274

Placer Community Action Council, Inc

1166 High Street Auburn, California 95603
Phone: 530 885-Kids Fax: 530 885-1902
Web: www.KidZKount.com

Child Eligibility Application

Child Information
Childs Legal Name:___________________ ____________________ ______________
(Last)

(Middle)

(First)

Date of Birth: __________________ (Please attach documentation)

Gender: Male
Female Ethnicity: _____________________________________________
Primary Language:_____________________ Secondary Language: _________________________
Street Address (including apartment #): __________________________________________________
City: ______________________________________ State: California Zip Code: _________________
Mailing Address (if different than above): _________________________________________________
City: ______________________________________ State: ___________ Zip Code: ______________
Health Insurance: (Please attach a copy)

Not insured MediCal Healthy Families: _________________

Indian Health Benefits Private Insurance: __________________

Physician Name: ____________________________________________________

Date of Last Physical Exam: ___________________ (Please attach Physical Exam)

Dental Insurance: (Please attach a copy)

Not insured MediCal Healthy Families: ______________

Indian Health Benefits Private Insurance: __________________

Dentist Name: _____________________________________________________

Date of Last Dental Exam: ___________________ (Please attach Dental Exam)

Diagnosed Medical Issues (Please indicate any diagnosed medical or biological issues currently affecting your child.)

Asthma
Diabetes
Eczema
Visual impairment
Seizure disorder Traumatic brain injury
Hearing impairment

Heart condition
Food allergy: __________________________
Bee Sting allergy
Other: ________________________________
Does your child require daily medication for diagnosed medical issues: Yes No

Diagnosed Disabilities (Please attach documentation) Date of last IEP/IFSP: ______________________________

Autism
Emotional/Behavioral
Orthopedic impairment Developmental Delay

Child Eligibility Application (May 2013)

License # 313602274

Speech Delay
Other: ______________

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Placer Community Action Council, Inc

1166 High Street Auburn, California 95603
Phone: 530 885-Kids Fax: 530 885-1902
Web: www.KidZKount.com

Parent / Guardian Information (The person signing the application should complete this section.)
Parent/Guardians Name:___________________ ____________________ ______________
(Last)

(Middle)

(First)

Date of Birth: __________________ Gender: Male Female Ethnicity: _________________

Relationship to child: _____________________ Pregnant: Yes No Due Date: ____________

Telephone: ( ) ________________
( ) ________________
( )________________
(Home)

(Work)

(Cell)

Primary Language: _____________________ Secondary Language: ________________________

Are you currently working: Part Time

Full Time Seasonal Unemployed

Are you currently enrolled in school: Yes No Name of School: ___________________________

Source of Income (Please check all that apply and attach documentation):

Wages TANF/AFDC CalWorks/CaLearn CalFresh Social Security

Unemployment Child Support Alimony/Spousal Support Disability Foster Subsidy
Are you paid: Weekly Monthly Twice Monthly Every 2 weeks Other: ___________
Highest Grade Completed: __________________ Degree: AA BA Masters Doctorate

Other Parent / Guardian Information

Parent/Guardians Name:___________________ ____________________ ______________
(Last)

(Middle)

(First)

Date of Birth: __________________ Gender: Male Female Ethnicity: _________________

Relationship to child: _____________________ Pregnant: Yes No Due Date: ____________

Telephone: ( ) ________________
( ) ________________
( )________________
(Home)

(Work)

(Cell)

Primary Language: ___________________ Secondary Language: __________________________

Are you currently working: Part Time

Full Time Seasonal Unemployed

Are you currently enrolled in school: Yes No Name of School: ___________________________

Source of Income (Please check all that apply and attach documentation):

Wages TANF/AFDC CalWorks/CaLearn CalFresh Social Security

Unemployment Child Support Alimony/Spousal Support Disability Foster Subsidy
Are you paid: Weekly Monthly Twice Monthly Every 2 weeks Other: ___________
Highest Grade Completed: __________________ Degree: AA BA Masters Doctorate
Living in the Home: Yes No

Child Eligibility Application (May 2013)

License # 313602274

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Placer Community Action Council, Inc

1166 High Street Auburn, California 95603
Phone: 530 885-Kids Fax: 530 885-1902
Web: www.KidZKount.com

Family Status

Two Parent Family Single Parent Family Single Parent Family with Partner Foster Family

Number of Adults in Family: _____________

Number of Children in the Family: _______________

List full names and birthdates of all children in the family:

Name (First, Middle, Last)

Date of Birth

Gender

1) ________________________________

_______________

Male Female

2) ________________________________

_______________

Male Female

3) ________________________________

_______________

Male Female

4) ________________________________

_______________

Male Female

5) ________________________________

_______________

Male Female

Family Circumstances
Has your family experienced any of the following in the past 12 months:

Child abuse or neglect

Divorce
Drug or alcohol abuse
Public Health Nurse Support Received
Parent or guardian is disabled
Open CPS Case
Restraining Order
Does your family receive WIC: Yes No

Death in the family

Domestic violence
Parent or guardian is incarcerated
Counseling Services Received
Military deployment
Family Resource Center Services Received
Other: _____________________________

Please add any other concerns you have for your child and/or your family:
________________________________________________________________________
________________________________________________________________________

What language do you prefer to communicate in should we have questions about the application?
Spoken:

English Spanish

Child Eligibility Application (May 2013)

Written:

English Spanish

License # 313602274

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Placer Community Action Council, Inc

1166 High Street Auburn, California 95603
Phone: 530 885-Kids Fax: 530 885-1902
Web: www.KidZKount.com

Residence Information
Does your family:

Own/Rent a Home
Temporarily Share a Home with Other People
Live in a Hotel/Motel
Live in a Shelter
Lack Regular Nighttime Housing Live in a Car, Park or Other Public Place

Childcare Needs

Does your child need full day childcare: Yes

No
Does your child need full year childcare: Yes No

Transportation

How will your child get to and from school everyday: Car

Public Transportation Other: __________________

I need transportation resources: Yes No

Walk Carpool

PCAC Employment

Are you or an immediate family member currently employed by PCAC: Yes No

Relationship to child: __________________________________________________

Recruitment Tracking
How did you hear about our program:

Event Name of Event: ___________________________________________________

Another Agency Name of Agency: ____________________________________________________________________________________

Sierra College TV Ad
Someone Came to My Door
Flyer
Banner
Past or Present Parent (Word of Mouth) Other: ___________________
Please note: You may be required to provide additional documents from your health care provider(s) and/or
your special education provider(s) prior to your child attending the program. In addition, a special written plan
may need to be agreed upon prior to your child attending the program. All submitted information will be kept
confidential.
------------------------------------------------------------------------------------------------------------------------------------------------I certify the information I have provided is accurate to the best of my knowledge. I understand I must provide
all required documentation in order for my application to be processed. I understand that completion of this
application does not guarantee enrollment.

_____________________________________

____________________

Parent/Guardian Signature

Date Signed

Child Eligibility Application (May 2013)

License # 313602274

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