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Application

Required

Cass County Head Start / Plattsmouth Early Childhood Center Preschool Application

My family is applying for
Time Frame

Child's Information

Applicants Legal Namerequired
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Gender
Was the child born before 37 weeks?
Ethnicity
Parent/guardian is a pregnant woman?
Does the child have a special need or disability?
Does the child have either?
Has the child been diagnosed by a physician to have any chronic medical diagnosis such as asthma, allergies, seizures, diabetes, etc?
Was the child referred to the program?
Were you referred for services by a child welfare agency?
Select services your child receives
Do you have legal custody of this child? *documentation of custody status may be required
Type of Custody

Family Information

Parental Status
Number of chidren by age
For each member of the family receiving income
Amount in dollars
Amount in dollars
Amount in dollars
Attach up to 1 file with a maximum size of 20MB
No file chosen
I choose not to submit income verification and understand that I will be required to pay the full preschool rate each month.
Are any primary caregivers under the age of 20?
Do any primary caregivers have a disability or chronic physical, cognitive, or other health related condition or impairment?
Do any primary care givers have a mental illness
Are any primary care givers incarcerated
During the past 12 months has your employment or income changed?
Do housing costs exceed 30% of your income?
Is your family in need or in crisis
Does anyone in your family receive
Is at least one parent/guardian a member of the United States military
Are they deployed
Are they a veteran

Family Information

Please list all family members in the home.

First Family Member

Name
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Gender

Second Family Member

Name
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Gender

Third Family Member

Name
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Gender

Fourth Family Member

Name
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Gender

Fifth Family Member

Name
First Name
Last Name
Must contain a date in MM/DD/YYYY format
Gender
Attach up to 5 files with a maximum size of 10MB
No file chosen