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HCECC Screening Appointment
Please read and answer each question carefully and completely.
*Applicants must be 3 years old by 8/1/2021 to be eligible for head start.
*Applicants must be 4 years old by 8/1/2021 to be eligible for preschool.
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* Indicates required question
Child's First Name
*
Your answer
Child's Last Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Grade for 2021-2022 School Year
*
Head Start (3 years old by 8/1/2021)
Preschool (4 years old by 8/1/2021)
Early Entrance for Kindergarten (5 years old after 8/1/2021 but before 10/2/2021)
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Parent/Guardian Phone Number
*
Your answer
Household Street Address
*
Your answer
Zip Code
*
Your answer
Parent/Guardian Email Address
*
Your answer
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