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Re-Enrollment Packet English
English Re-Enrollment Pre-Form
Please fill out the information below.
Center
C.A.F.E. Center (Head Start)
Eagledale (Head Start, Early Head Start)
Goodwin Center (Head Start, Early Head Start)
Hamilton County (Head Start, Early Head Start)
Pike Plaza (Head Start)
Service Center 2 (Head Start)
Southeast Center (Head Start, Early Head Start)
Windsor Village East (Head Start)
Southwest Center (Head Start, Early Head Start)
Windsor Village West (Head Start, Early Head Start)
Child's Name
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Date of Birth
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Date Format: MM slash DD slash YYYY
Child Allergies
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Child Medications
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Primary Health Coverage
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Insurance/Medicaid #
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Dental Coverage
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Dental Coverage #
*
Dentist’s Office Name, Address, Phone #
*
Doctor’s Office Name, Address, Phone #
*
Adult's Name
*
First
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Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Phone
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