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  • Beaufort Jasper EOC Head Start Pre-Application Enrollment/ Intake Form

    Beaufort Jasper EOC Head Start Pre-Application Enrollment/ Intake Form

  • Office Use Only

  • P.O Box 2296- Beaufort, SC, 29901-2296

    Telephone (843) 962-3888 Fax (843) 589-1197  Email- familysupport@thebjeoc.org

  • PROGRAM APPLYING FOR: (check one)

  • SECTION A. CHILD APPLICANT OR PRENATAL MOM

  •  - -


  •  - -

  • ADDITIONAL CHILD APPLICANT (if applicable)

  •  - -

  • SECTION B. HOUSEHOLD INFORMATION (List all members in the household including child applying for. Use codes below)

  • Use the following key for entries in the table below:

    Race  AA -African American/Black C -Caucasian/White  M -Bi-Racial A - Asian O- Other: Specify 

    Ethnicity - N -Not Hispanic H -Hispanic U -Unknown

    Language E -English S -Spanish O -Specify

    Highest Education Level HS -High School Diploma, GED -General Education Diploma, 10 -Grade 10, 9 -Grade 9 or less, 11 -Grade 11, B -Bachelor, 12 -(did not graduate), TC -Training Certificate, M -Masters, SC - Some College

    Relationship to Child F -Father, P -Partner, SP -Step Parent, B -Brother, GP -Grand Parent, S -Sister, M -Mother, AA -Associate, M -Mother, FP -Foster Parent, O -Other 

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  • SECTION C. PARENT OR GUARDIAN CONTACT INFORMATION

  • SECTION D. HOUSEHOLD/ LIVING ARRANGEMENTS

  • Father’s/Mother’s Information (if not living in household):

  • SECTION E. EMPLOYMENT/ FINANCIAL ASSISTANCE

    (Head of Household)
  •  / /

  • SECTION E. EMPLOYMENT/ FINANCIAL ASSISTANCE

    (Secondary Adult, if applicable)
  •  / /

  • SECTION F. Please check all that currently apply to family or child:

  • SECTION G. Transportation

  • SECTION H. HOW DID YOU HEAR ABOUT US?


  • CERTIFICATION: PLEASE READ, SIGN AND DATE YOUR APPLICATION

  • I hereby certify that the information contained in this application for program services is true and correct to the best of my knowledge and understanding. No false or misleading statements have been made by me or anyone representing me. The acceptance of the application DOES NOT guarantee that services will be performed under any program, and that services are dependent on many things including accurate applications, availability of finding and determination that the applicant qualifies for the program

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