Head Start/Early Head Start Recruitment Form
Please complete the following questions below.  A Head Start representative will contact you within the next 5 business days to assist your family with completing the enrollment application. 
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Child's First and Last Name
Child's Date of Birth
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DD
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Child's Gender
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Parent's First and Last Name
Parent's Date of Birth
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/
DD
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YYYY
Phone Number 
Email Address
Home Address
Mailing Address
What county do you live in?
Which Head Start center would you be interested in?
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Does your child have a diagnosed disability? (IEP or IFSP)
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If required, would you be able to transport your child to and from the center?  
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How did you find out about our program?
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