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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:

2017-2018

Phone/ Teléfono: Date: Fecha

Date: