Head Start & Early Head Start Application

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This field is for validation purposes and should be left unchanged.

DOB*

If other specify*

PRIMARY PARENT / LEGAL GUARDIAN #1

DOB*

Other Relationship to Child*

EMAIL*

PRIMARY PHONE:*

Highest grade completed if you did not Graduate*

PRIMARY PARENT / LEGAL GUARDIAN #2

DOB

EMAIL

PRIMARY PHONE:

Highest grade completed if you did not graduate

If YES, what State/County*

If Other, please specity*

If Other:*

ADDITIONAL CONTACT PERSON(S) IF WE ARE UNABLE TO REACH YOU:

Relationship to Child

Phone

Relationship to Child

Phone

PLEASE READ STATEMENTS BELOW CAREFULLY BEFORE SIGNING

Application will not be complete until we have proof of income.
Family income is the income of the biological parent(s) or guardian(s) living in the household. For enrollment purposes, I understand that RWCFS Head Start/Early Head Start may need to coordinate programming with my local school district, WI Shot Registry, other home visitation programs, and/or daycare providers for transportation, placement, 4K registration, and scheduling.
By signing, I verify that I am the parent/legal guardian of this child and that the information provided is correct and complete to the best of my knowledge.
I further understand that if I knowingly provide false information, that my family may no longer be eligible for further services.

Sign and Date

(When both parents live in the home, then both should sign whenever possible)

Parent/Guardian Signature*

Enter today's date*

Parent/Guardian Signature

Enter today's date

Are contacts awere they are a contact and can pick the child if needed?

Thank you for your patience.
It takes some time to process applications.