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: M-F 8:30am -4:30pm

Parents must be working or in school to apply
We will keep your application on file until May 2021 and we will contact you if we have an opening at the center of your choice.

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.