Kai Ming Head Start

Application

950 Powell Street, San Francisco, CA 94108

'    415-982-4777 / Fax 415-982-4120

 

 

Preferred Center首選分校:  

O 950 Powell St.          O820 Battery St. am/pm         O 1170 Columbus Ave.                        O 426 33rd Ave.             O 6221 Geary Blvd.         O 2800 Taraval St.

 跑華街           （上午/下午）   北岸區                     三十三亞運由       基利大道        日落區

 

Child’s Last Name:

學生姓氏﹕

First Name:

名字﹕

Nickname:

小名﹕

Date of Birth:       /          /

出生日期﹕

Sex:       F / M

性別﹕ 女/男

Total Family Gross Income:  Monthly: $

全家扣稅前總收入﹕              每月

or Yearly: $

或每年

Primary Language:

主要語言﹕

If immigrants, how long has family been in U.S:

如新移民，已在美國居留多久﹕

                                                                                                                                                                                                 

Address:                                                                                                Apt. #

住址﹕                                                                   

 

San Francisco, CA

Zip Code:

郵區號碼﹕

Phone:   Home﹕                                                 Voice Mail﹕

電話﹕ 家居﹕                     口訊﹕

Work Phone:        

工作電話號碼﹕               

Parental Status: (circle one)    One Parent             Two Parents                Foster                 Not Child’s Parent          Other Arrangement

                                                                             (same household)

家庭狀況﹕（選一）           單親                  雙親（同一住所）     寄養               非孩子父母                  其他生活安排

Number in Family Living in the Same Household  (          )

同住的家人總人數﹕                 

Number of Children:   In Family (          )       Under 6  (         )

孩子數目﹕                     家中共有孩子                六歲以下

 

Father’s/Guardian’s Name:

父親/監護人姓名﹕

Employment Status (circle one)   Working    Not Working   School/Training

就業狀況                （選一）    現正工作   沒有              上學/受訓

Mother’s/Guardian’s Name:

母親/監護人姓名

Employment Status (circle one)   Working    Not Working   School/Training

就業狀況                （選一）    現正工作   沒有              上學/受訓

 

Family receives the following public assistance: 有接受下列的社會福利﹕TANF:       Y      N                                  S.S.I.:      Y    N

                                                                                                                         福利金﹕是    否                               傷殘金﹕  是   否

 

Housing (circle one):        Own             Rent             Public Housing                   Homeless/Shelter        Live with Relatives

房屋﹕（選一）             擁有            租住                公共房屋                                                                                                    沒有住所                現與親人一起住

 

Does child have a disability or special need?     Y     N     Suspected    (Describe: if disability has been diagnosed, give date & source.)

孩子有殘障或特別需要嗎？                                           是    否     有懷疑       （請描述﹕如有醫生檢驗，請註明日期及檢驗者）

 

 

 

Applications will not be accepted without evidence of income, age and residency.  See attached instructions.

凡未填妥此表格或未附繳最近兩期的收入證明影印本，申請表將不獲審核。

 
 
 


  

 

 

 

 

Certification: The information above is accurate to the best of my knowledge.  I understand that providing false information will result in termination of Head Start services.

                  以上為本人所提供的最正確資料。我明白如果提供不真實資料，將隨時被終止獲得啟蒙學校的所有服務。

 

 

Parent/Guardian’s Signature:                                                                                          Date:                                       

家長/監護人簽名                                                                                                          日期

 

Text Box: STAFF USE ONLY 職員專用 Application Received By (Print Name): on