Head Start Policy Council Membership Application
All prospective Policy Council representatives must complete this application. The purpose is to ensure that no person serving on the Western Dairyland E.O.C., Inc. (WDEOC) Head Start Policy Council has a conflict of interest with the WDEOC Board of Directors and its employees.
Today's Date
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Month
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Day
Year
Your Contact Information
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State
Postal / Zip Code
Home Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Center/Program I represent:
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I am applying as (Check ONE that applies)
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A current Head Start/Early Head Start parent
A past Head Start/Early Head Start parent
A community representative
Have you served on Policy Council in the past?
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Yes
No
The number of years served:
DIRECTORY: Western Dairyland will create a Policy Council directory with members’ names, phone numbers, and email addresses. This directory will only be shared between Policy Council members and staff. Please check ALL that apply:
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Include my contact information in the Policy Council Directory
Do not include my contact information in the Policy Council Directory
I opt "IN" to received text message reminders and notices (message and data rates may apply).
ACKNOWLEDGEMENT - Please INITIAL each statement
I am not an employee of WDEOC or the Eau Claire Area School District (ECASD).
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Initial Here
I am not a consultant with WDEOC.
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Initial Here
I am not related to a WDEOC employee or an ECASD employee in any of the following ways: Parent | Spouse | Children | Sibling | Aunt | Uncle | Niece | Nephew | Grandparent | Parent-in-Law | Legal Guardian
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Initial Here
If elected, I understand that I am responsible for attending the annual Policy Council orientation and all monthly Policy Council meetings and reporting to my Parent Committee group. I understand that if I miss two meetings unexcused, I will be replaced as Policy Council representative by my Parent Committee.
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Initial Here
Submit
Should be Empty: