(Affix Card)
												                                    COMPLETION MEMO

CHILD’S NAME __________________________________ PARENT’S NAME_______________________________

PROGRAM ________________________________________________________________________________

In order to complete your child’s application for Early Head Start/Head Start/GSRP consideration, we must have the following documentation.   Without this information your child cannot be placed on a prioritized waiting list and will not be considered for placement in a classroom.  Please use the attached, stamped envelope, if provided.   Otherwise, text, fax, or e-mail to____________________________________________.

          ____Child’s Immunization Records
 
          ____ Proof of Income for the last 12 months ~ Mail copy or FAX the following:

                     q 2019 Federal Tax Return                    q Child Support Documentation
		W-2’s preferred, or Pay Stubs          	        *  all children in the home 
	      q MDHHS Cash Assistance (FIP)           q Third Party/Family Income Status
                   q Disability, Social Security or               q Unemployment
		 SSI                                                           q     Foster Care Stipend/
                   q College Grants                                               Foster Care documentation
			            						                     
          ____ Copy of Child’s Birth Certificate	

           ____ Insurance Information_______________________________________________________________
		
          _____ Other Information:  ________________________________________________________________         
                   _________________________________________________________________________________                    
                   _________________________________________________________________________________

To be completed and sent with family after recruitment appointment for any missing documents.

12/18	(Revised 1/20)		                                                                                                        P:/headstart/universal/recruit/Completion Memo