Amador-Tuolumne Community Action Agency
Early Childhood Services 

               Head Start/Early Head Start and
California State Preschool Program

We offer these child development programs throughout Amador and Tuolumne Counties
In Tuolumne County:

•	Extended Day Classes for ages 3-5                                                                                                                      8:30-2:30 Blue Bell, Jamestown, and Soulsbyville; 9:00-3:00 Summerville

•	Full-Day Classes for toddlers, 18 months- 3 years                                                                                                                     7:50-2:00 Blue Bell & 8:00-2:10 Jamestown 
•	Home Visiting Program for children birth to three years of age and pregnant mothers

Our programs are free of charge

Our programs provide children with kindergarten readiness skills while ensuring they are healthy and ready to learn. Parents are offered opportunities to learn leadership skills, volunteer in the classroom, and have access to our family services staff for parent education, support services and referrals to community agencies. Early Childhood Services provides meals in the center-based programs by participating in the federally funded Child Care Food Program.
.
We are an equal opportunity provider.

Application Instructions

•	To apply for services, please stop in or call one of our centers, or call (209) 533-0361 ext. 240, to set up an in-take interview with one of our staff members. 
•	During the interview, we will assist you in completing an application and determine if we have all the documentation needed to establish your child’s eligibility. To help us do this, you will be asked to bring the following to your interview:
•	Your child’s birth certificate (not needed for pregnant women)
•	One month’s worth of income or proof of homelessness or foster care
•	Your child’s immunization record
•	Families of children with disabilities are encouraged to apply (please bring IFSP/IEP)
•	After your in-take interview, application and documentation are complete, your child’s eligibility status will be determined. 
•	Eligible children are prioritized for placement in the program according to our selection criteria. Please keep in mind that submitting an application and completing an in-person interview does not mean your child has automatically been accepted in our program. 
•	We will contact you when an opening in your preferred program is available. 

If you have any questions about Early Head Start, Head Start, California State Preschool 
or applying for services, please call (209) 533-0361 ext. 240

Tuolumne Eligibility Application
 A.   Parent/Guardian: Full name including middle initial

	Gender:
□ Male

□ Female	Birth date	Phone Numbers:
Home
Cell
Work
Text	
Relationship to enrolling child:   □  Mother        □  Father        □  Grandparent        □  Foster parent        □  Relative other than grandparent   
                                                   
                                                   □  Other________________________________________________________                	
Primary Language:           	Secondary Language:	Ethnicity/Race:	Medical Insurance:
 Yes - If yes what type?     No
 MediCal       
 Other, list type: _____________ 	Marital Status:	Education Level:	Veteran of US Military:

 Yes     No	
 A.   Parent Street Address:
	City	State	ZIP Code	Current Member of US Military:

 Yes     No	
 A.   Parent Mailing Address:
	City	State	Zip Code		
A. Parent/Guardian
Employer/School Name:   

Occupation:	Work/School Schedule:	SUN	MON	TUE	WED	THUR	FRI	SAT	Total Hours 
Per Week:	
B.   Parent/Guardian: Full name including middle initial

	Gender:
□ Male

□ Female	Birth date	Phone Numbers:
Home
Cell
Work	
Relationship to enrolling child:   □  Mother        □  Father        □  Grandparent        □  Foster parent        □  Relative other than grandparent

                                                   □  Other________________________________________________________                	
Primary Language:	Secondary Language:	Ethnicity/Race:	Medical Insurance:
 Yes - If yes what type?      No
 MediCal        Healthy Families 
 Other, list type: ____________	Marital Status:	Education Level:	Veteran of US Military:

 Yes     No	
 B.   Parent Street Address:
	City	State	ZIP Code	Current Member of US Military: 

 Yes     No	
B. Parent/Guardian
Employer/School Name:   

Occupation:	Work/School Schedule:	SUN	MON	TUE	WED	THUR	FRI	SAT	Total Hours 
Per Week:	

(EHS) PREGNANT MOTHERS:  Due Date (mm/dd/yy): ______/ ______/______    Are you receiving prenatal services?  □ Yes  □ No

Please state any special concerns about this pregnancy: ______________________________________________________________	

Family Eligibility- Check all that apply:	
□ Child Protective Services	□ Working	□ Attending school or job training	
□ Preschool experience	□ Actively Seeking Employment	□ Parent/Guardian incapacitated 	
□ Infant or Toddler Care	□ Cal Works	□ Foster Child	
□ Pregnant	□ Homeless	□ Other:	

Family Annual Gross Income.   Check one range:
*Actual calculations of income will be made upon receipt of your income documentation.	
□ $0-$10,000	□ $10,001-$15,000	□ $15,001-$20,000	Family size:	
□ $20,001-$25,000	□ $25,001-$30,000	□ $30,001 +		
□ All proof of income received for the month is attached: such as pay stubs, letter from employer, current notice of action from
                                                                                                  Social Services or Social Security, child support, disability or unemployment.  	

LIST ALL CHILDREN residing in the home to be counted in the family size. 
PREGNANT MOTHERS: please put “unborn” for child’s name and estimated Birth Date.

(List enrolling children first)	
1. Full name of child (include middle initial)                                  
	Gender:
 Male
 Female	Birth Date                                                
	Ethnicity/Race	Primary 
Language	
Does this child have any Special Needs 
or a Disability?   Yes   No 

If yes, explain:
  	Medical Insurance:
 Yes - If yes what type?         No
 MediCal          Healthy Families 
 Other, list type: ____________	Secondary 
Language	
2. Full name of child (include middle initial)                                  
	Gender
 Male
Female	Birth Date        

	Ethnicity/Race	Primary 
Language	
Does this child have any Special Needs 
or a Disability?   Yes   No 

If yes, explain:
  	Medical Insurance:
 Yes - If yes what type?         No
 MediCal          Healthy Families 
 Other, list type: ____________	Secondary 
Language	
3. Full name of child (include middle initial)                                  

	Gender
 Male
 Female	Birth Date                           	Ethnicity/Race	Primary 
Language	
Does this child have any Special Needs 
or a Disability?   Yes   No 

If yes, explain:
  	Medical Insurance:
 Yes - If yes what type?         No
 MediCal          Healthy Families 
 Other, list type: ____________	Secondary 
Language	
4. Full name of child (include middle initial)                                  
	Gender
 Male
 Female	Birth Date                            	Ethnicity/Race	Primary 
Language	
Does this child have any Special Needs 
or a Disability?   Yes   No 

If yes, explain:
  	Medical Insurance:
 Yes - If yes what type?         No
 MediCal          Healthy Families 
 Other, list type: ____________	Secondary 
Language	

      Does your child (age 3-5) need help with potty training?     Yes     No

      Do you or anyone else have any concerns about this child’s overall health, development, learning or behavior?      Yes      No   

	If yes, please explain: _______________________________________________________________________________________

      Has the enrolling child attended a daycare or preschool in the past?    Yes    No     If yes, where? _______________________________

      Are you receiving WIC services?     Yes   No   Previously
				
      Are you receiving CalFRESH services (food stamps)?     Yes   No   Previously

      Are you receiving TANF services (cash aid)?     Yes   No   Previously

      How did you find out about ATCAA Early Head Start--Head Start---State Preschool?

 Internet     Newspaper      Radio      Flyer      Banner or booth         Friend or relative         TV        Other ________________

      Are you an ATCAA employee?    Yes    No     Are you related to an ATCAA employee?    Yes    No    If yes, who _________________
        
                             (ATCAA employees or relatives of ATCAA employees must have their applications and placement approved by the 
                                Early Childhood Services Director and ATCAA Executive director prior to receiving ATCAA services.)
	                   
Mark 1st, 2nd, 3rd 	Class Name & Hours	Days	Ages	Location	
HEAD START & STATE PRESCHOOL (School-Year Program)	
	Blue Bell              8:30 am- 2:30 pm         	Mon-Fri	3-5	18080 Blue Bell Rd. E., Sonora
532-5455	
	Jamestown          8:30 am- 2:30 pm	Mon-Fri	3-5	18234 4th Ave., Jamestown
984-1617	
	Soulsbyville         8:30 am- 2:30 pm         	Mon-Fri	3-5	20300 Soulsbyville Rd., Soulsbyville
533-3143	
	Summerville        9:00 am- 3:00 pm         	Mon-Fri	3-5	18451 Carter St., Tuolumne
928-3651	
EARLY HEAD START (Year-Round Program)	
	Tuolumne Home Base	As scheduled	Pregnant Moms	Weekly in-home educational services.	
	Tuolumne Home Base	As scheduled	0-3 yrs	Weekly in-home educational services and twice monthly social play groups.	

	Blue Bell             7:50 am- 2:00 pm	Mon-Fri	18 months-3 yrs	18080 Blue Bell Rd. E., Sonora    
532-5455	
	Jamestown         8:00 am- 2:10 pm	Mon-Fri	18 months-3 yrs	10550 7th St., Jamestown
628-3370	

To be eligible for ATCAA Early Childhood Services programs, the following conditions must be met:
•	Be a resident of Tuolumne County.
•	Meet age requirements (Head Start children must be 3 years of age; State Preschool children must be 3 years of age by September 1; Early Head Start children must be 0-3 years of age; Pregnant women can be any age). 
•	Meet the income guidelines (Federal Poverty Guidelines and/or State Income Ceilings) or be categorically eligible. 

Please bring the following to your in-take interview:
•	Your child’s Birth Certificate 
•	Proof of income (pay stubs, unemployment, disability, SSI/SSA, child support, foster care, TANF, W2, statement etc.)    or proof of homelessness or foster care, or CalFRESH
•	Immunization records for your child                         
•	If your child has a disability, bring a copy of his or her IFSP or IEP.

I certify under penalty of perjury that any other adults living in the home whose income is not listed are not the biological, adoptive, or step mother/father of my child(ren). Furthermore, I certify that the information in this enrollment application is true and complete to the best of my knowledge. If any part is false or omitted, my participation in this agency’s programs may be terminated and I may be subject to legal action. I understand that my eligibility may be reviewed by representatives of the State of California and the Federal Government.

Parent/Guardian Signature:  ______________________________________________________________ Date: _______________

Email address: _________________________________________________________________________ (optional)

If there are questions about my application, I prefer to be contacted by:  phone	 text message		 e-mail	

To apply for services, please stop in or call one of our centers, or call (209) 533-0361 ext. 240, to set up an in-take interview with one of our staff members.
If you have any questions about Early Head Start, Head Start, California State Preschool, 
or applying for services, please call (209) 533-0361 ext. 240.	

What’s next…..?  After your child’s eligibility has been determined, you will receive a letter to confirm the status of your application. As we need to be able to communicate with you about your child’s eligibility and possible placement in our program, please contact us if your address or phone number(s) changes.  All information provided will be treated confidentially and will be used only for determining eligibility. 

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. 

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.  Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.  Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call 
(866) 632-9992. Submit your completed form or letter to USDA by: 

(1)      mail: U.S. Department of Agriculture 
Office of the Assistant Secretary for Civil Rights 
1400 Independence Avenue, SW 
Washington, D.C. 20250-9410; 

(2)      fax: (202) 690-7442; or 

(3)      email: program.intake@usda.gov.

This institution is an equal opportunity provider.