Pre-Application (English)

I am interested in*

Head Start

Early Head Start

Home Based School District Enhanced Option

Child's Name*

Date of Birth (or Due Date)*

Parent/Guardian Name*

Parent/Guardian Date of Birth

Mailing Address*

Daytime Phone Number*

Cell Number

Total Household Annual Income $*

Number of adults in household*

Number of children in household*

Please check all that apply:

Our family's income is below income guidelines

TANF

SSI

Homeless

Foster

Our family's income is over income guidelines, but please consider my child because of IEP/IFSP

Head Start/Early Head Start Income Guidelines

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