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Please complete this pre-registration form and someone from our team will contact you with more details about our Head Start programs. We are looking forward to speaking with you!
Parent/Guardian Name
Phone Number
Can we text you?
Yes
No
Email
Zip Code
Primary Language
I'm Interested In
Prenatal Education
Family In Home Child Care
Center Child Care
Home Based Learning
Do you receive any of the following services or financial assistance
Publicly Funded Child Care (PFCC)
Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance to Needy Families (TANF)
Supplemental Security Income (SSI)
Individualized Family Service Plan (IFSP)
Foster Care
Are you experiencing homelessness?
Yes
No
Child's Name
Child's Date of Birth
How did you hear about us?
Community Agency
Current or Former EHS Family
Family
Friend
Provider
Event
Website
Other
If this is an agency referral, please write your agency and email.