Head Start Enrollment Application

Date

Full Name:*

First NameMiddle NameLast Name

Birth Date:

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone:*

Area CodePhone Number

E-mail:*

Language:

Gender:

Race:

Education Level

Are you receiving HEAP benefits?*

Are you receiving WIC?

Are you receiving Food Stamps / SNAP?

Employment Status:

Employer Name / School Name

United States Military Status:

Parent/Guardian Best Descriptor:

Family Structure:

Single ParentTwo Parent

Number in Family:

Number in Household:

Marital Status:

Family Type:

Disabled?

Medical Insurance:

Current Housing:

Comments:

Is there a Secondary Caregiver?

YesNo

Signature*

Clear

CAP Staff Signature

Clear

Eligibility Application