Administrative Office
4600 Carnegie Ave.
Cleveland, OH 44103
Phone: 216-391-8333
Fax: 216-391-8282

Kids in rocking boat

Pre Application Recruitment Form

* These fields are required.
Parent/Guardian's Name*
Address 1
Address 2
City
State
Zip
Home Telephone*
Work Telephone
Pager/Mobile Phone
Child's Name*
Date of Birth*
Number of Family Members
Number of Age Eligible Siblings
Currently has voucher	Yes No
Eligible for voucher	Yes No
Special Needs	Yes No
Services Needed
	full day half day A.M. P.M.
Preferred Site
Preferred Hours of Service
Monthly Income*
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