Family Development Services: Head Start: Prospective Student Application Form

Please complete this form to begin the 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.

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Child's Information *Child First Name:
*Child Last Name:
*Date of Birth:
(mm/dd/yyyy) / /
*Gender:
*Health Insurance: Type:
*Dental Insurance: Type:
*Race:
*Child's Primary Language:
*Ethnicity:
*Does the child have any special needs or disabilities that require any special accomodations?:
*Is your child diagnosed with a current IFSP or IEP?:
*School District:

Family Information & Demographics *Parent Full Name:
*Relationship to Child:
*Date of Birth:
(mm/dd/yyyy) / /

*Mailing Address:
*City:
*State:
*Zip:

*Home Phone: - -
Work Phone: - -
Cell Phone: - -
Email Address:
Sex:
Employed:
School/Job Training?:
Household Parental Status
Do you have primary custody of this Head Start Eligible Child?:
Housing Type:
Educational Status:
Languages spoken in the home:
Number of Children in the Home:
Number of Adults in the Home:
Family Services Received:

Other Parent/Legal Guardian Information Parent Full Name:
Relationship to Child:
Date of Birth:
(mm/dd/yyyy) / /

Mailing Address:
City:
State:
Zip:

Home Phone: - -
Work Phone: - -
Cell Phone: - -
Email Address:

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

Other Information *Program:

*Number in Household:
*Gross Income (2008):
(total amount before taxes)

Interpreter Required?
If Yes, what language?

Center Applying For:
Second Choice Center:

How You Heard About Us:

Signature

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

Parent/Guardian:

Comments Comments: