Pre-Enrollment Form EHS | Family Development Services

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

Program

Center Preference:

Second Option:

Program Preference

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

Applicant Child:

*First Name:

*Last Name:

*Birthday:
(mm/dd/yyyy)

*Gender:

*Race:

*Hispanic:

*English Proficiency:

*Other Language:

*Other Language Proficiency:

*Primary Health Coverage:

*Other/Secondary Coverage:

*Medicaid Eligibility:

*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:

*If yes, sibling name:

*Does your child have any disability, special health or developmental concern (More information will be collected during the interview:

*Does your child have an Individualized Education Plan (IEP) or Individualized Family Service Plan (IFSP) ex: Speech, Developmental, Occupational Therapy:

Primary Adult:

*First Name:

*Last Name:

*Birthday:
(mm/dd/yyyy)

*Gender:

*Race:

*Hispanic:

*English Proficiency:

*Other Language:

*Other Language Proficiency:

*Highest Grade Completed

*Employment Status:

*Child's Relationship:

*Custody:

*Check all that apply for this adult

Lives with FamilyProvides Financial SupportTeen Parent
Do you need an interpreter for your appointment?

*Email Address:

Secondary Adult:

*Check all that apply for this adult

Lives with FamilyProvides Financial SupportTeen Parent
Do you need an interpreter for your appointment?

*Email Address:

Family Information

*Parental Status:

*Primary Language at Home:

*Homeless Family:

*Active Military:

*Military Veteran:

*Referred by DCS:

*Receiving SNAP:

*WIC:

*Supplemental Security Income (SSI):

*Temporary Assistance for Needy Families (TANF):

Primary Adult

*Living Address:

*City:

*State:

*Zip:

*County:

*Mailing Address:

*City:

*State:

*Zip:

*County:

*Is this the child's legal address?:

*Phone:

Type of Phone:

*Text Messages:

*Additional Phone:

Type of Phone

*Text Messages:

Second Adult

Other Non-Applicant Children in Family

First:

Last:

Birthday:
(mm/dd/yyyy)

Relation to Child:

Gender:

First:

Last:

Birthday:
(mm/dd/yyyy)

Relation to Child:

Gender:

First:

Last:

Birthday:
(mm/dd/yyyy)

Relation to Child:

Gender:

First:

Last:

Birthday:
(mm/dd/yyyy)

Relation to Child:

Gender:

First:

Last:

Birthday:
(mm/dd/yyyy)

Relation to Child:

Gender:

Please answer the following questions:
*Does your child have any fears?

*Does your child easily form relationships with adults and or peers?

*Would your consider your child curious?

*Does your child manage care of own needs appropriately?

Parent/Guardian Consent

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

Comments:

Please enter the characters above.