HRDC Head Start/Early Head Start
Online Enrollment Application
Complete a Separate Application for Each Child
Parent/Guardian #1 Name
*
First Name
Last Name
Parent/Guardian #1 Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian #1 Role
*
Mom (biological or adopted)
Dad (biological or adopted)
Step-Parent
Grandparent
Other Relative
Foster Parent
Legal Guardian
Other
Parent/Guardian #2 Name
First Name
Last Name
Parent/Guardian #2 Date of Birth
-
Month
-
Day
Year
Date
Parent/Guardian #2 Role
Mom (biological or adopted)
Dad (biological or adopted)
Step-Parent
Grandparent
Other Relative
Foster Parent
Legal Guardian
Other
Child's Name (name of child you are applying for)
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Child's Pediatrician
First Name
Last Name
Child's Dentist
First Name
Last Name
Does this child have an IEP or IFSP?
*
Yes
No
Will this child attend Pre-K in the fall?
*
Yes
No
Unsure
If yes, which elementary school?
Program Applying for:
*
Head Start (ages 3-5)
Early Head Start (ages birth to 3)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
example@example.com
Does anyone in your family receive any of the following?
*
TANF
SNAP (food stamps)
SSI
None
Do you currently live with a friend or another family member or in temporary housing?
*
Yes
No
Estimated Monthly Family Income
*
No $ Sign, Whole Number
Income Source #1
*
Employment Parent #1
Employment Parent #2
Child Support
TANF
Unemployment Benefits
Other
No Income
Income Source #2
Employment Parent #1
Employment Parent #2
Child Support
TANF
Unemployment Benefits
Other
Income Source #3
Employment Parent #1
Employment Parent #2
Child Support
TANF
Unemployment Benefits
Other
Total Number in Your Family
If available, include a picture of the child's birth certificate.
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of
If available, include a picture of your proof of income.
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of
Signature
Submit
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