Language
  • English (US)
  • Español
  • English Español
  • 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 Drawer 9, Beaufort SC 29901

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

  • PROGRAM APPLYING FOR: (check one)

  • Program (Select the most appropriate):*
  • Will your child turn 3 before Sept 1st, 2026?*

  • SECTION A. CHILD APPLICANT OR PRENATAL MOM

  • DOB*
     - -
  • Do you have a concern about your child's speech?
  • Does the child have an IEP or IFSP?
  • Does the child have a diagnosed disability?
  • Does child receive services in any of the following areas:

  • Health Insurance: (Check One)
  • Foster Child:

  • Expected Due Date:
     - -

  • ADDITIONAL CHILD APPLICANT (if applicable)

  • DOB:
     - -
  • Does the child have a diagnosed disability?
  • Does the child have an IEP or IFSP?
  • Do you have a concern about your child's speech?
  • Does child receive services in any of the following areas:

  • Health Insurance: (Check One)
  • Foster Child:

  • 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 

  • Rows

  • SECTION C. PARENT OR GUARDIAN CONTACT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Would you like to be notified by text messaging on the cell number provided?
  • Would you like to be notified via e-mail? **This is our primary way of sending updates about your application. **

  • SECTION D. HOUSEHOLD/ LIVING ARRANGEMENTS

  • Family Type:
  • Marital Status:
  • Incarcerate Parent?
  • Active Military?
  • Military Veteran?

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

  • Living Arrangements:

  • SECTION E. EMPLOYMENT/ FINANCIAL ASSISTANCE

    (Head of Household)
  • Choose one of the following:
  • Format: (000) 000-0000.
  • Full Time Student (documentation required):
  • Last date of employment:
     / /
  • Type of Financial Assistance:*

  • Would you like Head Start to request a copy of your SNAP print out to assist with determining if your family is eligible for the program?*

  • SECTION E. EMPLOYMENT/ FINANCIAL ASSISTANCE

    (Secondary Adult, if applicable)
  • Choose one of the following:
  • Format: (000) 000-0000.
  • Full Time Student (documentation required):
  • Last date of employment:
     / /
  • Type of Financial Assistance:

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

  • SECTION G. Transportation

  • Does your family have reliable transportation?
  • Do you have a child enrolled with the Beaufort or Jasper County District?

  • SECTION H. HOW DID YOU HEAR ABOUT US?

  • Contact

  • 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

  • Date:
     / /
  • Proof of parent/guardian income from previous year or previous 12 months. Includes, at least, ONE of the following:
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof
  • Browse Files
    Cancelof

  • For Staff Only

  • Should be Empty: