EHS/HS PARENT CONTACT INFORMATION
Thank you for your interest in our program.  Please complete this form for once for each family member eligible for program services.
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Please share your FIRST name. *
Please share your LAST name. *
Please share your CHILD'S FIRST name. (Please enter "NA" if you are hoping to enroll as a pregnant woman.) *
Please share your CHILD'S LAST name. (Please enter "NA" if you are hoping to enroll as a pregnant woman.) *
Please share your current HOME phone number. *
Please share your current CELL phone number. *
Please share an email address for an account you check regularly. *
What is the best way to reach you? (Please check all that apply.) *
Required
Which program are you interested in? *
Required
Please enter the CHILD'S current age in YEARS and MONTHS (example, "3 years/7 months"). If a pregnant woman, please enter age in years only (example, "22") *
Were you (if a pregnant woman) or your child actively enrolled in the CDI Early Head Start or Head Start program in December 2020? *
Thank you!  Someone from our staff will reach out to you very soon.  In the meantime, please leave any questions or comments you have here.  
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