Head Start Application Information

Intake Form

Instructions: After this form is completed, staff determines if the family is eligible or is likely to be eligible to receive Head Start services. You will receive a phone call. 

Name of Child:		Date of contact:
Name of Parent(s):
Address:
Street (Apartment number)		City                       State    Zip
Possible Center:		Home Phone:
Primary Language?	EnglishSpanishSpanishOther (Indicate Below)	Work Phone:
		Message Phone:

Child Information

	1.	Age: Birth date: Is child 3 before September 1 of the current school year? Yes Is child 4 before September 1 of the current school year? Yes
	2.	Income: Annual Amount: $     Number of Adults in Family: Number of Children in Family: (Income can be from prior 12 months or prior calendar year.)
	3.	Mark any that may apply to child and family. Children with: documented disability special needs medical risk: Foster child SSI TANF Returning child from previous year (OHCAC Head Start or additional Head Start program) Child from a high-risk family: homeless domestic violence abuse family medical issues: Child referred by OHCAC Head Start for: disability special needs medical risk: Single parent/guardian home or living with relative other than parent Primary language other than English

How did you hear about Head Start?



Head Start staff will contact you for an appointment and further information.

  06/22/2006