Head Start Interest Form 24/25 School Year-1

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Please complete an Interest Form for EACH CHILD that you are interested in filling out an application for.

CHILD'S FIRST NAME *

CHILD'S LAST NAME *

CHILD'S DATE OF BIRTH *

YYYY

PARENT/GUARDIAN FIRST NAME *

PARENT/GUARDIAN LAST NAME *

PARENT/GUARDIAN DATE OF BIRTH *

YYYY

PARENT/GUARDIAN PHONE NUMBER

(no dashes)

PARENT/GUARDIAN EMAIL

STREET ADDRESS *

CITY *

ZIP CODE

DOES YOUR FAMILY RECEIVE ANY OF THE FOLLOWING? *

SNAP

TANF

SSI FOR ANYONE IN THE HOUSEHOLD

NONE OF THE ABOVE

ARE YOU COMPLETING THIS FORM FOR A FOSTER CHILD? *

YES

IS YOUR FAMILY EXPERIENCING HOMELESSNESS? *

YES

HOW MANY PEOPLE ARE IN YOUR HOUSEHOLD *

WHAT IS YOUR HOUSEHOLD INCOME? *

UNDER $20,440

BETWEEN $20,440 - $25,819

BETWEEN $25,820 - $31,199

BETWEEN $31,200 - $36,579

BETWEEN $36,580 - $41,959

BETWEEN $41,960 - $47,339

BETWEEN $47,340 - $52,719

OVER $52,720

WHAT IS YOUR FAMILY'S PRIMARY LANGUAGE? *

DID YOU NEED ASSISTANCE COMPLETING THIS FORM?

YES

Submit

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