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step up to quality
Pre Application Recruitment Form
Personal Information
parent/guardian's name
(required)
address
city
state
zip
home telephone
(required)
work telephone
pager/mobile phone
Children Information
child's name
(required)
date of birth
(required)
number of family members
number of age eligible siblings
Voucher
currently has voucher
yes:
no:
eligible for voucher
yes:
no:
Services
special needs
yes:
no:
services needed
full day:
half day:
A.M.:
P.M.:
preferred site
preferred hours of service
Monthly Income
monthly income
(required)
source
How did you hear about our head start program?
TV
Radio
Visited a center
Community/Health Fair
Parent at center
Staff
Friend
Collaborative Site
Social Service Agency
CEOGC
Shopping cart
Newspaper
other