Lewis-Clark Early Childhood Program On-line Enrollment Form

Size of family unit HS/EHS ECEAP

1............................................................ $10,830              $11,231
2........................................................... $14,570               $15,059
3........................................................... $18,310               $18,887
4............................................................ $22,050               $22,715
5............................................................ $25,790                $26,543
6............................................................ $29,530                $30,371
7............................................................ $33,270                $34,199
8............................................................ $37,010                $38,027

For each additional person: Head Start add $3,740 / ECEAP add $3,828

Please report any problems with this form to Mary Asker:: masker@lcecp.org. Thank you!

Date:
Parent's Name:
Address:
City, State and Zip:
Home Phone:
Business/Message Phone:
Child's Name:
Child's Birthday:
For Expectant Parents: Due Date of Child
*You will be contacted to set an appointment.* When contacted for an appointment, you will be asked to bring the following documents: § Child’s Birth Certificate or Birth Verification § Child’s Immunizations Record § Social Security Numbers for all family members § Income verification: Ex. Income tax or pay stubs § Medical Insurance Cards Submitting this form doesn't automatically enroll your child. Income Guideline for Head Start, Early Head Start and ECEAP Size of family unit HS/EHS ECEAP 1............................................................ $10,830 $11,231 2........................................................... $14,570 $15,059 3........................................................... $18,310 $18,887 4............................................................ $22,050 $22,715 5............................................................ $25,790 $26,543 6............................................................ $29,530 $30,371 7............................................................ $33,270 $34,199 8............................................................ $37,010 $38,027 For each additional person: Head Start add $3,740 / ECEAP add $3,828 Source: HS/EHS; ACF-IM-HS-09-02, March 12, 2009 Please report any problems with this form to Mary Asker:: masker@lcecp.org. Thank you!