[Type text]
HEAD START CHANGE OF STATUS CAMBIO DE CONDICIÓN Effective Date: Name of Child: Nombre del Nino
Center: Nombre del Sitio
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Drop / Despido
Reason / Razón:
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Transfer / Transferencia
Campus:
Teacher: Nombre de Maestra
Teacher:
Reason: □
Re-enrollment / Inscripción segunda
Child withdraws before 10:00 a.m./use that day’s date as drop date; Child withdraws after 10:00 a.m./use the next day’s date as drop date
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Name Change/Denomine el cambio: (must have legal papers)
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Change of Guardianship Name/Cambio de Guardián:
**For Child Plus, enter as "other adult" and check to make sure the number in family did not change on the Enrollment, Eligibility screen** New Guardian information: Gender: M F
Date of Birth:
Primary Language:
Race (check all that apply): American Indian/Alaska Native
Asian
Black/African American
Hawaiian/Pacific Islander
Highest Grade Completed: 9 grade or less 10 grade 11 grade 12 grade High School Graduate GED Associates Bachelors Masters th
th
th
th
White
Other:
Some College/Training
Employment Status: Full Time & Training Full Time 35 hrs + Part Time & Training Part Time Retired or Disabled Seasonal employed Training or School Unemployed Child’s Relationship to adult: Son/Daughter (Natural/Adopted/Step)
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Foster
Grandchild Niece/Nephew
Other:
Change of Address / Cambio de Dirección : Change of Phone:
home / cell / work
Cambio de Número de Teléfono
casa / cellular / trabajao
Person to Contact in case of Emergency / Nombre de persona para llamar en caso de emergencia: Name/Nombre Relationship/ Parentesco:
Parent/Guardian Signature: Firma de padre o guardián
Entered into Child Plus by:
2019-2020
Phone/ Teléfono: Date: Fecha
Date: