Upshur Head Start

Enrollment Application

CONFIDENTIALITY STATEMENT: This information is being requested on a voluntary basis. However, some information is required to determine eligibility. All information disclosed will be used only by those persons related to the program and who are on a need-to-know basis.

Child to be Enrolled Age:

I am enrolling a child in Pre-K, who will be 4 years old on or before June 30th.

I am enrolling a 3-year-old.

I am enrolling a child transitioning from birth to three.

Child's First Name

Child's Last Name:

Child's Gender:

Male

Female

Child's Birthday:

Month

Day

Year

Child's Address:

Directions to Child's Home:

Number of People in Primary Family:

Name of Parent/Guardian #1:

Parent #1 Address (if different from child):

Parent #1 Date of Birth:

Parent #1 Email:

Parent #1 Primary Phone:

Parent #1 Primary Employer:

Parent #1 Work Email:

Parent #1 Work Phone:

Parent #1 Highest Level of Education Completed:

Name of Parent/Guardian #2:

Parent #2 Address (if different from child):

Parent #2 Date of Birth:

Parent #2 Email:

Parent #2 Primary Phone:

Parent #2 Primary Employer:

Parent #2 Work Email:

Parent #2 Work Phone:

Parent #2 Highest Level of Education Completed:

Other People in the Home (include name, birthdate, relationship to child):

Emergency Contact #1 Name:

Emergency Contact #1 Phone:

Emergency Contact #2 Name:

Emergency Contact #2 Phone:

Name of Caregiver for Child During the Day:

Do You Need Before/After School Care?:

No

Yes

Are There Known Custody Issues?:

No

Yes

Please Explain ANY Known Custody Issues:

* Any custody restrictions must be documented by court order. A copy of the court order must be provided to the Head Start office.