Head Start Enrollment Application

Date

Full Name: *

First Name Middle Name Last Name

Birth Date:

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone: *

Area Code Phone Number

E-mail: *

Language:

Gender:

Race:

Education Level

Bachelor or Advanced Degree College Degree or Training School Certificate ESL GED High School Graduate No High School Some College / Vocational / Associates Degree Highest Grade Completed _______ Unknown

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 Parent Two Parent

Number in Family:

Number in Household:

Marital Status:

Family Type:

Single Parent Male Single Parent Female Two Parent Household Two Parent Unmarried Other

Disabled?

Medical Insurance:

Current Housing:

Comments:

Is there a Secondary Caregiver?

Yes No

Signature *

Clear

CAP Staff Signature

Clear

Eligibility Application

Eligibility Application Con't

Child Application