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:
Number of children applying?
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

Other
Adult #2 Name

First NameMiddle NameLast Name
Adult #2 Date of Birth

MonthDayYear
Relationship to Child

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which county do you live in?
Please Specify County
This address is:
Phone Number 1

Area CodePhone Number
Phone Number 2

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

Other
Are your currently pregnant?
What is the due date?

MonthDayYear
By whom were you referred?

Rows	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)?
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
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.