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:

Number in Family:

Number in Household:

Marital Status:

Family Type:

Disabled?

Medical Insurance:

Current Housing:

Comments:

Is there a Secondary Caregiver?

Signature

CAP Staff Signature

Eligibility Application