LCAA Returning Student Application

Lowcountry Community Action Agency, Inc. Head Start Program Returning Student Application for Year 2021 - 2022
Student's Name: First
Last
Student DOB
Parent(s) Name
Parent Email
example@example.com
Residential Address (Living Address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pick-Up/Drop-Off Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Daytime Phone
Second Number
Parent's Place of Employment
Employer Phone
Emergency Names, Addresses, and Telephone Numbers (required):
1.
2
3
Parent Signature/Date

Clear
Should be Empty: