Head Start/Early Head Start Recruitment Form

If you are interested in your child attending Head Start or Early Head Start, please fill out this form and submit. A Head Start or Early Head Start coordinator will contact you within a few days to discuss your information and set up a home visit.

Do you live in Clinton County or Franklin County?

Clinton County

Franklin County

School Year

School District

Parent/Guardian

First Name

Last Name

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name

First Name

Last Name

Birth Month and Year

Health Concerns (if applicable)

Special Needs

Social Services Received

TANF

SNAP

Does anyone in the household receive SSI?

Yes

If yes, who?

Number of people in household

Approximate Monthly Income

Head Start/Early Head Start Recruitment Form

Info

Action

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