HCECC Screening Appointment
Please read and answer each question carefully and completely.

*Applicants must be 3 years old by 8/1/2021 to be eligible for head start.

*Applicants must be 4 years old by 8/1/2021 to be eligible for preschool.

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Child's First Name *
Child's Last Name *
Child's Date of Birth *
Child's Grade for 2021-2022 School Year *
Parent/Guardian First Name *
Parent/Guardian Last Name *
Parent/Guardian Phone Number *
Household Street Address *
Zip Code *
Parent/Guardian Email Address *
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