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L.K.L.P. HEAD START/EARLY HEAD START 165 CARR CREEK HILL ROAD RED FOX, KY 41847 TELEPHONE: 606-642-3317

Which program are you applying for?:	Early Head Start Pre-School Head Start
*County of residence:
*Child's Name:
*Date of Birth:
Does your child have a disability?:	Yes No Suspected
What is the name of the childs father?:
What is the name of the childs mother?:
*Phone Number:
*Mailing Address:
Is the mother pregnant?:	Yes No
*Number of individuals in the family:
*Number of children 0-5 years old?:
Please list any special needs your child may require:
*Directions to childs home:

THE L.K.L.P. HEAD START PROGRAM SHALL NOT DISCRIMINATE AGAINST ANY APPLICANT BECAUSE OF SEX, RACE, CREED, NATIONAL ORIGIN, RELIGION OR DISABILITY.

BELOW ARE THE INCOME GUIDELINES FOR 2008 AS THEY APPEARED IN THE FEDERAL REGISTRY.

SIZE OF FAMILY UNIT POVERTY

GUIDELINES

1------------------------------------------------------------------------------------10,400

2------------------------------------------------------------------------------------14,000

3------------------------------------------------------------------------------------17,600

4------------------------------------------------------------------------------------21,200

5------------------------------------------------------------------------------------24,800

6------------------------------------------------------------------------------------28,400

7------------------------------------------------------------------------------------32,000

8------------------------------------------------------------------------------------35,600

FOR EACH ADDITIONAL PERSON ADD 3,600