Rosemount Center Application

Page 1 of 8

Rosemount Center Application

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 (EHS):

Financial assistance for families who qualify, center-based and home-based program

DC Department of Human Services assistance (DHS):

Financial assistance for families who qualify, tuition center-based program

Tuition:

Center-based program

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

Application Date*

Invalid Input

Program Options*

Center-based
Home-based
Invalid Input

Age Group*

Infant/Toddler (0-3 yrs)
Pre-school (3-5 yrs)
Invalid Input

Payment Options (check one)*

Invalid Input

Applicant
(Child Applying for Services)

First Name*

Invalid Input

Middle Name

Invalid Input

Last Name*

Invalid Input

Suffix

Invalid Input

Nickname

Invalid Input

Birthday*

|| Invalid Input

Gender*

Male
Female
Invalid Input

Race*

Invalid Input

Other Race

Invalid Input

Nationality (Country of Birth)*

Invalid Input

English Proficiency*

Invalid Input

Other Language

Invalid Input

Other Language Proficiency

Invalid Input

Primary Adult
(Lives with child)

First Name*

Invalid Input

Middle Name

Invalid Input

Last Name*

Invalid Input

Suffix

Invalid Input

Nickname

Invalid Input

Birthday

/ / Invalid Input

Gender*

Male
Female
Invalid Input

Race*

Invalid Input

Race*

Invalid Input

Nationality (Country of Birth)*

Invalid Input

English Proficiency*

Invalid Input

Other Language

Invalid Input

Other Language Proficiency

Invalid Input

Highest Grade Completed*

Invalid Input

Employment Status*

Invalid Input

Child's Relationship*

Invalid Input

Custody*

Yes
No
Invalid Input

Check all that apply*

Lives with Family
Provides Financial Support
Teen Parent
Invalid Input

If teen parent, subsidized?

Yes
No
Invalid Input

Contact Information
for Primary Adult lives with Child

Living Address*

Invalid Input

City*

Invalid Input

State*

Invalid Input

Zip*

Invalid Input

Ward #

Invalid Input

Home Phone*

Invalid Input

Work Phone

Invalid Input

Cell Phone

Invalid Input

E-mail Address*

Invalid Input

Secondary Adult
(Lives with child)

Is there a secondary Adult that lives with the child that you would like listed on the application.

Yes
No
Invalid Input

First Name

Invalid Input

Middle Name

Invalid Input

Last Name

Invalid Input

Suffix

Invalid Input

Nickname

Invalid Input

Birthday

/ / Invalid Input

Gender

Male
Female
Invalid Input

Race

Invalid Input

Race

Invalid Input

Nationality (Country of Birth)

Invalid Input

English Proficiency

Invalid Input

Other Language

Invalid Input

Other Language Proficiency

Invalid Input

Highest Grade Completed

Invalid Input

Employment Status

Invalid Input

Child's Relationship

Invalid Input

Custody

Yes
No
Invalid Input

Check all that apply

Lives with Family
Provides Financial Support
Teen Parent
Invalid Input

If teen parent, subsidized?

Yes
No
Invalid Input

Contact Information
for Secondary Adult

Cell Phone

Invalid Input

Home Phone

Invalid Input

Work Phone

Invalid Input

E-mail Address

Invalid Input

Family/Household Information

Child lives with*

No Parent
One Parent/Adult
Two Parents/Adults
Invalid Input

Children in family living with child

Total children ages birth to 18

Invalid Input

Number of children ages Birth to 3

Invalid Input

Number of children ages 4 to 5

Invalid Input

Family Members
(Please do not include adults and child listed previously)

Number of family members living with child

Invalid Input

Family Member (1)

Name

Invalid Input

Relationship to Child

Invalid Input

Date of Birth (month/day/year)

/ / Invalid Input

School/Current Grade or Occupation

Invalid Input

Live with family?

Yes
No
Invalid Input

Provides financial support?

Yes
No
Invalid Input

Family Member (2)

Name

Invalid Input

Relationship to Child

Invalid Input

Date of Birth (month/day/year)

/ / Invalid Input

School/Current Grade or Occupation

Invalid Input

Live with family?

Yes
No
Invalid Input

Provides financial support?

Yes
No
Invalid Input

Family Member (3)

Name

Invalid Input

Relationship to Child

Invalid Input

Date of Birth (month/day/year)

/ / Invalid Input

School/Current Grade or Occupation

Invalid Input

Live with family?

Yes
No
Invalid Input

Provides financial support?

Yes
No
Invalid Input

Family Member (4)

Name

Invalid Input

Relationship to Child

Invalid Input

Date of Birth (month/day/year)

/ / Invalid Input

School/Current Grade or Occupation

Invalid Input

Live with family?

Yes
No
Invalid Input

Provides financial support?

Yes
No
Invalid Input

Family Member (5)

Name

Invalid Input

Relationship to Child

Invalid Input

Date of Birth (month/day/year)

/ / Invalid Input

School/Current Grade or Occupation

Invalid Input

Live with family?

Yes
No
Invalid Input

Provides financial support?

Yes
No
Invalid Input

Government Funding Information

To be considered for Early Head Start and/or DHS (District of Columbia), please indicate which of the following services your family receives. (Check all that apply)

Medical Financial assistance (i.e. Medicaid/Medicare)
Public assistance/Welfare (i.e. TANF)
Food Stamps
Women, Infants, and Children (WIC)
Supplemental Security Income (SSI)
Foster care/Adoption subsidy
Unemployment Insurance
Public Housing Assistance
Energy Program Assistance
Child support/Alimony
DHS Voucher
Other/Specify
Invalid Input

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.

Invalid Input

*

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.
Invalid Input

*

Invalid Input

Rosemount Center Application