Head Start & Early Head Start Pre-Registration Form

Today's Date

CHILD 1 APPLICANT INFORMATION

Child's Name (#1)

First

Last

Date of Birth *

Gender *

Date of last physical/ TB test *

Known allergies (write n/a if none): *

Does child have IEP/IFSP? *

Yes

No

Is child in Foster Care? *

Yes

No

If yes, please provide name and contact information of DCF worker.

CHILD 2 APPLICANT INFORMATION

Child's Name (#2)

First

Last

Date of Birth

Gender

Date of last physical/ TB test

Known allergies (write n/a if none):

Does child have IEP/IFSP?

Yes

No

Is child in Foster Care?

Yes

No

If yes, please provide name and contact information of DCF worker.

ADULT INFORMATION

Name *

First

Last

Employment *

Do you receive TANF or SSI? *

Yes

No

Primary Language *

FAMILY CONTACT INFORMATION

Address *

Address

City

State/Province

Zip/Postal

Country

Phone *

Email

Apply Today

CHILD 1 APPLICANT INFORMATION

CHILD 2 APPLICANT INFORMATION

ADULT INFORMATION

FAMILY CONTACT INFORMATION

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