*Child First Name:

*Child Last Name:

*Date of Birth:
(mm/dd/yyyy)

*Gender:
---MaleFemale
*Health Insurance:
---YesNo
Type:

*Dental Insurance:
---YesNo
Type:

*Race:
---Black/African AmericanWhite/CaucasianAsianAmerican IndianOther
*Child's Primary Language:
---EnglishArabicSpanishAsianEuropean-SlavicOther
*Ethnicity:
---White(Non-Hispanic)Black(Non-Hispanic)Asian/Pacific IslanderHispanic/LatinoAmerican IndianPuerto RicanOther
*Does the child have any special needs or disabilities that require any special accomodations?:
---YesNo
*Is your child diagnosed with a current IFSP or IEP?:
---YesNo
*School District:

*Parent Full Name:

*Relationship to Child:
---Biological ParentGrandparentAdoptive ParentStep ParentLegal GuardianAunt/UncleSignificant OtherFoster Parent
*Date of Birth:
(mm/dd/yyyy)

*Mailing Address:

*City:

*State:
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
*Zip:

*Home Phone:

Work Phone:
<
Cell Phone:

Email Address:

Sex:
---MaleFemale
Employed:
---YesNo
School/Job Training?:
---YesNo
Household Parental Status
---Single ParentFoster ParentNon-parentTwo ParentsGrandparent
Do you have primary custody of this Head Start Eligible Child?:
---YesNonePartial
Housing Type:
---RentOwnHomelessOther
Educational Status:
---Grade 9 or lessHigh School DiplomaAdvance Training/CertificateDegree
Languages spoken in the home:
---EnglishArabicSpanishAsianEuropean-SlavicOther
Number of Children in the Home:

Number of Adults in the Home:

Family Services Received:
---TANFSSIUnemploymentWICFood StampsSubsidized Housing

Parent Full Name:

Relationship to Child:
---Biological ParentGrandparentAdoptive ParentStep ParentLegal GuardianAunt/UncleSignificant OtherFoster Parent
Date of Birth:
(mm/dd/yyyy)

Mailing Address:

City:

State:
---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Do you live in the household with the Parent/Legal Guardian
---YesNo

*Program:
---Head StartEarly Head Start
*Number in Household:
---1234567 or more
*Gross Income (2012):
(total amount before taxes)

Interpreter Required?
---NoYes
If Yes, what language?
SelectAfrican LanguagesArabicAsian LanguagesFrenchFrench CreoleIndianSpanishOther
Center Applying For:
SelectCAFECrooked CreekDecaturWestfieldGoodwin CenterSchool 75Service Center 1Service Center 2SoutheastSouthwestSt. Peters
Second Choice Center:
SelectCAFECrooked CreekDecaturWestfieldGoodwin CenterSchool 75Service Center 1Service Center 2SoutheastSouthwestSt. Peters
How You Heard About Us:
SelectRadioTVCommunity CalendarFlyerFriend/FamilySigns/Billboards/BannersInternetEmployeePrevious Enrollment

 I certify that all information provided on this application is accurate to the best of my knowledge.
Parent/Guardian: