0-5 Head Start Policy Council Candidate Interest Form

0-5 Head Start Policy Council
Candidate Interest Form
Anyone who is interested in running to serve on the EightCAP, Inc. 0-5 Head Start Policy Council must complete this Candidate Interest Form. The following information may be used on the ballot for an upcoming election.
Interested Individual’s Name:
Address:
City:
State:
Zip Code:
Phone Number:
E-mail Address:
example@example.com
Are you or your child currently enrolled in the Head Start or Early Head Start program?

YesNo
Child’s Name (if applicable):
If yes, in which of the following EightCAP, Inc. program options are you or your child enrolled?

Head StartEarly Head Start Center-BasedEarly Head Start Home-Based
Please write a brief description about yourself and a statement of why you wish to serve on the Policy Council. This information will be printed on a Ballot Form to be distributed to all current Head Start and Early Head Start Parents/Legal Guardians in future elections for a seat on the 0-5 Head Start Policy Council.
Brief Description:
By placing my signature below, I attest that the information that I have provided on this form is true and accurate. I also give EightCAP, Inc. permission to publish the information that I provided on this form on a ballot for an election for a seat on the 0-5 Head Start Policy Council.
Signature*
Date

MonthDayYear
Date
Approved by Policy Council on 10/25/16
Should be Empty: