Grand Portage Head Start Enrollment Application This application is for:New StudentRe-EnrollmentPregnant/Expecting Mother Student First Name Student Middle Initial Student Last Name Student Age Student Sex Student Birth Date or Due Date Student RaceNative American or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMiddle Eastern or North AfricanWhiteNative Hawaiian or Pacific Islander Mailing Address (Street, City, State, Zip) Physical Address (Street, City, State, Zip) Family Information Caregiver #1 Caregiver 1 is a:ParentFoster ParentRelative/Guardian Caregiver 1 First Name Caregiver 1 Middle Initial Caregiver 1 Last Name E-mail Address Phone Number Birth Date Race Type of Medical Coverage: Highest Level of EducationGrade SchoolHigh School/GEDVocational TrainingSome CollegeAssociate’s DegreeBachelor’s DegreeMaster’s Degree Job Training Where Employment StatusFull TimePart TimeSeasonalUnemployedRetired/Disabled Employer Name Employer Phone Number Caregiver #2 Caregiver 2 is a:ParentFoster ParentRelative/Guardian Caregiver 2 First Name Caregiver 2 Middle Initial Caregiver 2 Last Name E-mail Address Phone Number Birth Date Race Type of Medical Coverage: Highest Level of EducationGrade SchoolHigh School/GEDVocational TrainingSome CollegeAssociate’s DegreeBachelor’s DegreeMaster’s Degree Job Training Where Employment StatusFull TimePart TimeSeasonalUnemployedRetired/Disabled Employer Name Employer Phone Number Family StatusOne ParentTwo ParentsMarriedSingleSeparatedDivorced Child lives withBoth parentsMotherFatherFoster ParentsRelative/Guardian List everyone else who lives in the household Name Birth Date Gender Relationship Name Birth Date Gender Relationship Name Birth Date Gender Relationship Name Birth Date Gender Relationship Submit
