2020-2021 Porter-Leath Early Head Start Recruitment Questionnaire
Complete the following questionnaire to start the process for the Early Head Start application. Please only complete one form per child.
Email address *
Untitled Title
Primary Parent Name *
Your answer
Child's Name *
Your answer
Child's Date of Birth *
MM
/
DD
/
YYYY
Address (zip code included) *
Your answer
Phone Number *
Your answer
Early Head Start Site of Interest *
Best Time of Day to be Contacted *
Required
Is either parent currently employed by Porter-Leath? *
Are you currently pregnant? *
A copy of your responses will be emailed to the address you provided.
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