Families
Partners & Volunteers
Employment
Governing Bodies
Please complete this form to begin the Head Start application process. All fields marked with an * are required. If you have questions, look at our FAQ, or contact us.
Pre-Enrollment Form
Center Preference: SelectEagledale 5425 W 34th StGoodwin Center 3935 W Mooresville RdHamilton County 17645 Oakmont Dr, NoblesvilleSoutheast 4024 MadisonSouthwest 1130 S Kappes StWindsor Village 5950 E 23rd St Second Option: SelectEagledale 5425 W 34th StGoodwin Center 3935 W Mooresville RdHamilton County 17645 Oakmont Dr, NoblesvilleSoutheast 4024 MadisonSouthwest 1130 S Kappes StWindsor Village 5950 E 23rd St
*Early Head Start: M-F 8:30am -4:30pm
*First Name: *Last Name: *Birthday:(mm/dd/yyyy) *Gender: ---MaleFemale *Race: ---Black/African AmericanWhite/CaucasianAsianAmerican IndianHawaiian/Pacific IslanderMulti-Racial/BiracialOther *Hispanic: ---YesNo *English Proficiency: ---LittleModerateNoneProficient *Other Language: ---NoneSpanishBurmeseChinArabicOther *Other Language Proficiency: ---LittleModerateNoneProficient *Primary Health Coverage: ---MedicaidPrivate (through Individual/Employer)No InsuranceOther *Other/Secondary Coverage: ---MedicaidPrivate (through Individual/Employer)No InsuranceOther *Medicaid Eligibility: ---Not EligibleOn MedicaidApplied (Potentially) *Insurance Medicaid #: *Doctor/Medical Provider: *Doctor's Office Name, Address, Phone #: *Dental Coverage Provider: *Dental Coverage #: *Dentist's Office Name, Address, Phone #: *Does child have a sibling attending in Head Star/Early Head Start: ---YesNo *If yes, sibling name: *Does your child have any disability, special health or developmental concern (More information will be collected during the interview: ---YesNo *Does your child have an Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP) ex: Speech, Developmental, Occupational Therapy: ---YesNo
*First Name: *Last Name: *Birthday:(mm/dd/yyyy) *Gender: ---MF *Race: ---Black/African AmericanWhite/CaucasianAsianAmerican IndianHawaiian/Pacific IslanderMulti-Racial/BiracialOther *Hispanic: ---YesNo *English Proficiency: ---LittleModerateNoneProficient *Other Language: ---NoneSpanishBurmeseChinArabicOther *Other Language Proficiency: ---LittleModerateNoneProficient *Highest Grade Completed ---Grade 9 or lessGrade 10Grade 11Grade 12GEDHigh School GradAdv. TrainingSome CollegeAssociatesBachelorsMasters *Employment Status: ---Full TimePart TimeSeasonalUnemployedFull Time & SchoolPart Time & SchoolSchool/TrainingRetired or Disabled *Child's Relationship: ---Biological/Adopted/StepGrandchildNiece/NephewFosterOther *Custody: ---YesNonePartial
Lives with FamilyProvides Financial SupportTeen Parent Do you need an interpreter for your appointment? ---YesNo *Email Address:
*Parental Status: ---OneTwo *Primary Language at Home: *Homeless Family: ---YesNo *Active Military: ---YesNo *Military Veteran: ---YesNo *Referred by DCS: ---YesNo *Receiving SNAP: ---YesNo *WIC: ---YesNo *Supplemental Security Income (SSI): ---YesNo *Temporary Assistance for Needy Families (TANF): ---YesNo
*Living Address: *City: *State: ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming *Zip: *County: ---MarionHamilton *Mailing Address: *City: *State: ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming *Zip: *County: ---MarionHamilton *Is this the child's legal address?: ---YesNo *Phone: Type of Phone: ---CellHomeWorkOther *Text Messages: ---YesNo *Additional Phone: Type of Phone ---CellHomeWorkOther *Text Messages: ---YesNo
First: Last: Birthday:(mm/dd/yyyy) Relation to Child: Gender: ---MF First: Last: Birthday:(mm/dd/yyyy) Relation to Child: Gender: ---MF First: Last: Birthday:(mm/dd/yyyy) Relation to Child: Gender: ---MF First: Last: Birthday:(mm/dd/yyyy) Relation to Child: Gender: ---MF First: Last: Birthday:(mm/dd/yyyy) Relation to Child: Gender: ---MF
*I certify that all information provided on this application is accurate to the best of my knowledge. *Parent/Guardian Signature:
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