EARLY HEAD START PRE-ENROLLMENT INFORMATION

Which County do you live in: Choose One Howard Miami

Today's Date: 

Parent or Guardian Name:

Address:

City:      Zip Code:

Telephone Number:      Second Number:

Is it OK to leave a message on these phone numbers? Choose One Yes No

GENERAL INFORMATION

Child's Name:      Age:      Birthday:

Does your child have a diagnosed disability?   Choose One Yes No

If yes, please describe:

Has your child attended a Head Start program in the past? Choose One Yes No

If yes, where?

Are any members of the household expecting? Choose One Yes No

If yes, name of expectant individual      Due Date

INCOME VERIFICATION

Total number of family members living in your home (Including expectant infants as 1):

Weekly Income:      Annual Income:

Do you receive TANF (AFDC)? Choose One Yes No

Do you receive SSI for any household members? Choose One Yes No

REFERRAL SECTION

Is this a referral from a community agency/partner? please choose one Yes No

If yes, please tell us the referring agency's name:

also, please tell us the person's name referring:

Click Submit one time to send your pre-application to the Family and Community Partnership Manager for EHS.