Early Head Start Application for Enrollment

Early Head Start Application for Enrollment

Serving Pregnant Women, Infants, and Toddlers up to age 3
I am applying for:*

Home Visiting Program (Weekly Visits)Center-BasedFirst Available (Home Visiting or Center-Based)
Number of children applying?*

None12
Child 1 - Name:

First NameMiddle NameLast Name
Child 1 - Gender:
Child 1 - Date of Birth

MonthDayYear
Date
Child 2 - Name:

First NameMiddle NameLast Name
Child 2 - Gender:
Child 2 - Date of Birth

MonthDayYear
Date
Adult #1 Name*

First NameMiddle NameLast Name
Adult #1 Date of Birth*

MonthDayYear
Relationship to Child*

MotherFatherOther
Adult #2 Name

First NameMiddle NameLast Name
Adult #2 Date of Birth

MonthDayYear
Relationship to Child

MotherFatherOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which county do you live in?*
Please Specify County
This address is:*

House/ApartmentFriend/Relative's HouseMotel/Shelter/Temporary Housing
Phone Number 1*

Area CodePhone Number
Phone Number 2

Area CodePhone Number
Email
example@example.com
Primary Language:*

EnglishSpanishOther
Are your currently pregnant?*

YesNo
What is the due date?

MonthDayYear
By whom were you referred?

	Yes	No
Were you under 20 years old when your first child was born?
Were you referred by a local agency (CPS, Foster Care, WIC)?
Does your family receive Supplemental Nutrition Assistance Program (SNAP)?

Do any of the above children have a special need (IFSP) or a home visitor (Early On, health care visitor)?

YesNo
If yes, which child?
Please indicate Worker Name/Agency (Early On, health care visitor, etc):

Any additional notes regarding recent income changes, family size, or other concerns?
I certify that the above information is correct and true to the best of my knowledge. I authorize the release of this information and educational records to be shared between EightCAP, Inc. 0-5 Head Start and any Intermediate School District.

Please use your mouse or finger to sign, then select Submit.
Signature*

Clear
Date*

MonthDayYear
State & Federally funded programs will not discriminate against anyone because of race, color, national origin, sex, age or disability.
Should be Empty:

Eligibility is based on child's age, family income, child's need, and available openings.