EHS/HS PARENT CONTACT INFORMATION

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Thank you for your interest in our program. Please complete this form for once for each family member eligible for program services.

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.) *

Phone Call

Text Message

Required

Which program are you interested in? *

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") *

Were you (if a pregnant woman) or your child actively enrolled in the CDI Early Head Start or Head Start program in December 2020? *

Yes

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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