2025/2026 Application Addendum

2025/2026 Application Addendum

Children Name*

Enter legal name and date of birth for each child.

example: Jane Doe November 13, 2019

Parent/Guardian Name*

Please enter as Legal First and Last

Phone Number*

Phone

Email Address*

Family Sources of Income

Check all sources of income for every family member that supports the child.

Retirement, Disability or Social Security*

Select

Retirement, Disability or Social Security Amount

Child Support*

Select

Child Support Amount

Foster Care/Adoption Assistance*

Select

Foster Care/Adoption Assistance Amount

Alimony*

Select

Alimony Amount

Santa Rosa County District Schools Head Start Prog*

Was your child/ren in your family enrolled in the Santa Rosa County District Schools Head Start program before this school year?

Select

SRCSD Head Start Student names

Enter Student(s) Legal Name

Migrant Farm Worker*

Is anyone in your family a migrant farm worker?

Select

Is at least one parent/guardian employed?*

Select

Is at least one parent/guardian in job training?*

Select

Is at least one parent/guardian in school?*

Select

Situations*

Please check all the following situations which apply to your family, either in the past or currently.

Select

Please check the appropriate box by the name of any agency providing services to your child:

Early Steps

Early Steps Services Provided

Department of Children & Families (DCF)

DCF Services Provided

Family First Network (FFN)

FFN Services Provided

Child Find

Child Find Services Provided

Other Agency

Other Agency Services Provided

None

Does your family live in a home that you own or rent?*

Select

If the answer to the question above is "YES", Stop and go to the Completed Application section.

Living with an Adult Not Guardian/Parent

Is the applicant (child) with an adult that is not a parent or legal guardian?

Select

Current Nighttime Residence of Child

Select the one response that best describes the current nighttime residence of the child(ren).

Select

Best description of temporary arrangement

Select the one response that best describes the cause of the temporary arrangement.

Select

Certification: I certify that this information is true. If any part is false, my participation in this program may be terminated. I also understand that the information in this application will be held in strict confidence within the program and is accessible to me during normal business hours.

Completed Application*

I understand that my child's completed application is only good for 2025/26 school year.

Parent/Guardians initials*

Please enter Initials

Send me a copy of my responses

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