Head Start Connections Intake Form

Head Start Connections Intake Form
Personal Information
Name*

First Name Middle Name Last Name Suffix
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number, or enter all 0s if you do not have a phone number.
Is this a mobile phone?*

YesNoNot applicable
Accepts text messages?*

YesNoNot applicable
Email*
example@example.com
Preferred contact method?*

PhoneEmailBoth
Are you legally authorized to work in the United States?*

YesNo
Are you a U.S. military veteran?

YesNo
Getting Started
Which training are you interested in?

Day cohortEvening cohort
What is your employment status?*
Who is your current employer, if applicable?
What is your highest education level?*
Typically, we schedule a 30–minute meeting with a Career Navigator to start. What time of day do you prefer to meet?*

MorningAfternoonEvening
Do you have a personal computer?

YesNo
Do you have internet access?

YesNo
How comfortable are you with technology (i.e., Zoom, Microsoft Suite)

1

2

3

4

5

1 is Not Comfortable, 5 is Very Comfortable
What is your Head Start location?*
Who is your Family Advocate/Parent Educator?
Should be Empty:

Personal Information