Pre-Enrollment Form
Parent/Guardian Name: *
Your answer
Name of Child:
Your answer
Birth Date of Child
MM
/
DD
/
YYYY
Foster Care?
Homeless?
Address:
Your answer
Phone Number: *
Your answer
E-mail:
Your answer
Total in Household:
Your answer
Estimated Household Income:
Your answer
Do you receive any of the following:
Any other concerns or questions?
Your answer
Submit
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This form was created inside of The Child Care Consortium - Head Start of LaPorte County.