Head Start Eligibility/Recruitment Form
This information is used to determine eligibility for participation in Head Start, Early Head Start, and/or Pre-K Counts.
Which Head Start program are you interested in?
Head Start (3-5 years old)
Early Head Start
Primary Caregiver
Primary Caregiver
First Name
Middle Initial
Last Name
Caregiver date of birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Are you receiving WIC?
Yes
No
Previously
Are you receiving food stamps?
Yes
No
What is your primary language?
English
Spanish
Other
Ethnicity
Latino
Non-Latino
Race
African American
Asian
Bi-racial/multi-racial
Native American
Pacific Islander
White
Unspecified
Other
Employer/School Name
Phone Number (home/primary)
Please enter a valid phone number.
Phone Number (mobile/secondary)
Please enter a valid phone number.
Phone Number (work)
Please enter a valid phone number.
Email
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Housing
Homeless
Rent
Own
Other
Family Income (select all that apply)
TANF (cash assistance)
SSI (not SSD)
No income
Employment wages
Unemployment compensation
Could you transport your child if selected?
Yes
No
Are there other children ages 0-5?
Yes
No
How did you hear about Head Start?
Alternate Contact
Name
Relationship
Alternate contact phone
Please enter a valid phone number.
Child's Data
Child's name
First Name
Middle Initial
Last Name
Is the child unborn?
Yes
No
Child's date of birth
*
-
Month
-
Day
Year
Date
Estimated due date
-
Month
-
Day
Year
Date
How did you hear about Head Start?
Word of mouth
Billboard
Radio ad
Facebook
Other
Submit
Should be Empty: