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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.
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Your answer
Please share your LAST name.
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Your answer
Please share your CHILD'S FIRST name. (Please enter "NA" if you are hoping to enroll as a pregnant woman.)
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Your answer
Please share your CHILD'S LAST name. (Please enter "NA" if you are hoping to enroll as a pregnant woman.)
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Your answer
Please share your current HOME phone number.
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Your answer
Please share your current CELL phone number.
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Your answer
Please share an email address for an account you check regularly.
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Your answer
What is the best way to reach you? (Please check all that apply.)
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Phone Call
Text Message
Email
Required
Which program are you interested in?
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Early Head Start (EHS - for children ages 6 weeks to 3 years)
Head Start (HS - for children ages 3 and 4 years)
Pregnant Woman
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")
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Your answer
Were you (if a pregnant woman) or your child actively enrolled in the CDI Early Head Start or Head Start program in December 2020?
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Yes
No
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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