CDI/Wayne Metro - Head Start Registration
Parent/Guardian
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender
E-mail Address *
Your answer
Mobile Phone
Your answer
Home Phone
Your answer
Work Phone
Your answer
Work Phone Ext.
Your answer
English Proficiency
Other Language
Child's Relationship *
Address
Is your family experiencing homelessness?
Living Address *
Your answer
Address Line 2
Your answer
City *
Your answer
State *
Your answer
ZIP *
Your answer
Mailing Address same as Living Address? *
Full Mailing Address
(If different than Living Address)
Your answer
Additional Parent/Guardian
Is there another parent/guardian in the family? *
Family Information
Primary Language at Home *
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? *
Is at least one parent/guardian an active duty member of the United States military? *
Is at least one parent/guardian a veteran of the United States military? *
Child (Applicant)
First Name *
Your answer
Middle Name
Your answer
Last Name *
Your answer
Suffix
Your answer
Nickname
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender
Race
Hispanic?
English Proficiency
Other Language
Other Language Proficiency
Location Preferences
Which program are you applying for? *
Which location are you applying for? *
Verification
*
Required
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