HeadStart Program Waitlist
Date
/
Month
/
Day
Year
Site Interested In:
*
Please Select
Morey Avenue Preschool
Oakdale Preschool
Rio Linda Preschool
Village Preschool
Child's Name:
*
First Name
Last Name
Child's Birthdate:
*
-
Month
-
Day
Year
First Parent / Guardian Name:
*
First Name
Last Name
First Parent / Guardian Birthdate:
*
-
Month
-
Day
Year
Second Parent / Guardian Name:
First Name
Last Name
Second Parent / Guardian Birthdate:
-
Month
-
Day
Year
Home Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
example@example.com
Are you pregnant at this time?
Yes
No
Categorical Eligibility (Public Assistance/Homelessness/Foster)
Yes
No
Monthly Gross Income (Please enter your gross income amount):
*
Family Size:
*
Does your child have a diagnosed special need?
Does your child have special dietary needs?
Are you currently/previously enrolled in another head start program in Sacramento County?
Yes
No
How did you hear about our HeadStart Program?
*
Income:
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Immunization Records:
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