Rosemount Center Application

Step 1 of 8

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Please complete all 7 sections of the application to the best of your ability.
If you are currently pregnant, please indicate the last name of the child and the due date. Note: When the child is born please call the enrollment department at Rosemount Center to update the information.

Enrollment Options

Early Head Start/Head Start:

Financial assistance for families who qualify. Early Head Start is a center-based and home-based program. Head Start is a center based program.

Office of State Superintendent of Education (OSSE):

Finance assistance for families who qualify for the Center Based Program.

Tuition:

Center based program for both Infant/toddler and Preschool programs.

Note: EHS/OSSE applicant must be a DC resident in order to qualify for the program.

Application Date(Required)

MM slash DD slash YYYY

Program Options(Required)

Center-based

Home-based

Age Group

Infant/Toddler (0-2 yrs)

Pre-School (3-5 yrs)

Payment Options(Required)

Your application will not be processed until we receive your application fee.

Applicant (Child Applying for Services)

Child's Full Name(Required)

First Middle Last

Suffix

"Sr.", "Jr.", "I", "II", "III", etc.

Nickname

Birthday(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Unknown

Race(Required)

Asian

Black

White

American Indian/Alaska Native

Hawaiian/Pacific Islander

Hispanic

Other

Nationality (Country of Birth)(Required)

English Proficiency(Required)

Other Language Child Speaks

Other Language Proficiency

Primary Adult (Lives with child)

Primary Adult Name(Required)

First Middle Last

Suffix

"Sr.", "Jr.", "I", "II", "III", etc.

Nickname

Birthday(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Race(Required)

Asian

Black

White

American Indian/Alaska Native

Hawaiian/Pacific Islander

Hispanic

Other

Nationality (Country of Birth)(Required)

English Proficiency(Required)

Other Language Primary Adult Speaks

Other Language Proficiency

Highest Grade Completed(Required)

Employment Status(Required)

Relationship to Child(Required)

Custody(Required)

Yes

Check all that apply(Required)

Lives with Family

Provides Financial Support

Teen Parent

Contact Information for Primary Adult lives with Child

Living Address(Required)

Street Address Address Line 2 City State ZIP Code

Ward #

Home Phone(Required)

Work Phone

Cell Phone

Email(Required)

Secondary Adult (Lives with child)

Is there a secondary Adult that lives with the child that you would like listed on the application?(Required)

Yes

Secondary Adult Full Name(Required)

First Middle Last

Suffix

"Sr.", "Jr.", "I", "II", "III", etc.

Nickname

Birthday(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Race(Required)

Asian

Black

White

American Indian/Alaska Native

Hawaiian/Pacific Islander

Hispanic

Other

Nationality (Country of Birth)(Required)

English Proficiency(Required)

Other Language Secondary Adult Speaks

Other Language Proficiency

Highest Grade Completed(Required)

Employment Status(Required)

Relationship to Child(Required)

Custody(Required)

Yes

Check all that apply(Required)

Lives with Family

Provides Financial Support

Teen Parent

If teen parent, subsidized?

Yes

Contact Information for Secondary Adult

Home Phone(Required)

Work Phone

Cell Phone

Family/Household Information

Child lives with(Required)

No Parent

One Parent/Adult

Two Parents/Adults

Children in family living with child

Total children ages birth to 18

Number of children ages 0 to 3

Number of children ages 4 to 5

Family Members

Public Housing Assistance

Energy Program Assistance

Child support/Alimony

DHS Voucher

Other/Specify

Development Information

Do you have any concerns about your child’s development, physical, or emotional progress? Has your child ever been assessed for special need? Does your child have an IEP or IFSP? If yes, please explain.

Certify Information(Required)

I certify that this information is true.

If any part is false, my participation in this agency’s programs may be terminated and I may be subjected to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.

Total

Credit Card(Required)

Card Details

Cardholder Name

Comments

This field is for validation purposes and should be left unchanged.

Rosemount Center Application

Enrollment Options

Early Head Start/Head Start:

Office of State Superintendent of Education (OSSE):

Tuition:

Applicant (Child Applying for Services)

Primary Adult (Lives with child)

Contact Information for Primary Adult lives with Child

Secondary Adult (Lives with child)

Contact Information for Secondary Adult

Family/Household Information

Children in family living with child

Family Members

(Please do not include adults and child listed previously)

Family Member (1)

Family Member (2)

Family Member (3)

Family Member (4)

Family Member (5)

Government Funding Information

Development Information

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