*PARTICIPANT INFORMATION - Fill out information about the child applying to the program
FAMILY INFORMATION - Fill out information about parents/guardians and family
Some College. If yes, what certificate/degree:
Some College. If yes, what certificate/degree
*List additional family members who are related to the parent/guardian by blood, marriage, or adoption* Please do not re-list those on page 1.
CHILD'S NEEDS: Please provide medical documentation of concerns, if available.
My signature below denotes that the above information is true and correct to the best of my knowledge.
ERSEA/head start early head start application Rev.: 2/23/22