Pre-Application Questionnaire/Cuestionario Inicial

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This is the First Step to Apply for Head Start or Early Head Start / Este es el primer paso para aplicar para Head Start o Early Head Start

Child's First Name (Nombre del Nino) *

Pregnant women enter mom's first name here / Mujeres embarasadas, pongan el nombre de la mama aqui

Child's Last Name (Apellido del Nino) *

Pregnant women enter mom's last name here / mujeres embarasadas, pongan el apellido del la mama aqui

Child's Date of Birth (Fecha de Nacimiento del Nino) *

Pregnant women enter mothers date of birth here / mujeres embarasadas, pongan la fecha de nacimiento de la mama aqui

Parent/Guardian's First Name *

(Nombre del Padre o Guardian)

Parent/Guardian's Last Name *

(Apellido del Padre o Guardian)

Contact Numbers (Numeros de Telefono)

Please put best contact number first / favor de poner el numero del mejor contacto primero

Mailing Address (Direccion del Correo) *

(Number and Street) (el numero y la calle)

Mailing Address (Direccion del Domicilio) *

(City, State, and Zip Code) (la ciudad, estado, y el codigo postal)

Email Address

(Direccion Electronica)

Can we contact you using a text message?

(We use google voice for this)

Yes

Call Only

Prefer email

Clear selection

Primary Contact Language *

(Idioma Primario de Contacto)

English / ingles

Spanish / espanol

Other:

Is there anything we should know about contacting your family? / Hay algo que debemos saber a cerca de como contactar a su familia?

For example: Only call between certain times or on certain days, live at different address than mailing address, etc. / por el emplo: solo llamar entre ciertas horas, o ciertos dias, viven en direccion diferente del codigo postal

Attempted Contact Date

For Office Use Only / solo para uso de oficina

YYYY

Scheduled Interview Date

For Office Use Only / solo para uso de oficina

YYYY

Interview Complete

For Office Use Only / solo para uso de oficina

Yes

Clear selection

Submit

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