HRDC Head Start/Early Head Start Initial Information Application
If you have questions, please call 301-783-1730 or email hsehs@alleganyhrdc.org.

Complete a separate application for each child.
Parent/Guardian #1 Name: *
Parent/Guardian #1 Date of Birth: *
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Parent/Guardian #1 Role: *
Parent/Guardian #2 Name:
Parent/Guardian #2 Date of Birth:
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Parent/Guardian #2 Role:
Child's Name (name of child you are applying for): *
Child's Date of Birth: *
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Name of Child's Pediatrician:
Name of Child's Dentist:
Does this child have an IEP or IFSP? *
Will this child go to Pre-K in the fall? *
If yes, what elementary school will they attend?
What program are you applying for? *
Family Address: *
Primary Phone Number: *
Alternate Phone Number:
Email
Does anyone in your family receive any of the following? *
Do you live with a friend or another family member or in temporary housing? *
What is your estimated monthly income? *
Income Source #1: *
Income Source #2:
Income Source #3:
Total Number in Your Family: *
If available, please email a picture of your child's birth certificate to hsehs@alleganyhrdc.org *
If available, please email a picture of your proof of income to hsehs@alleganyhrdc.org *
Please include your electronic signature below by typing your name. *
Submit
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