Family Development Services
 
 

Please complete this form to begin the Early Head Start application process. All fields marked with a * are required. If you have questions, look at our FAQ, or contact us. You can also download a PDF application here. You can download the medical and dental instructions letter here (PDF).

 Pre-Enrollment Form

Program





Program Preference

*Early Head Start: 10 hour (M-TH 7:30am - :30pm)

Applicant Child:













































Primary Adult:


























*Check all that apply for this adult

Lives with FamilyProvides Financial SupportTeen Parent




Secondary Adult:


























*Check all that apply for this adult

Lives with FamilyProvides Financial SupportTeen Parent




Family Information





















Primary Adult



































Second Adult



































Other Non-Applicant Children in Family



















































Please answer the following questions:








Parent/Guardian Consent

*I certify that all information provided on this application is accurate to the best of my knowledge.





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