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Head Start / Early Head Start
Recruitment Form for Early Childhood Services Division. Please fill out this form and we will get in touch with you shortly.
Check program(s) applying for:
Pre School (ages 3-5 on/after September 1) PD
Pre School (ages 3-5 on/after September 1) FD
Early Head Start Infants/Toddlers (under 3)
Early Head Start Home Based (under 3)
Early Head Start Expectant Moms
CHECK IF TRANSPORTATION IS REQUIRED
Applicants Name
*
First
Last
Birth Date
*
MM slash DD slash YYYY
Email
Is Applicant a Foster Child?
Yes
No
If yes, family income information is not required.
Does the family have a RSP from the TANF Program?
Yes
No
Parent/Guardian
First
Last
Relationship to Applicant:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County
We service WILL County
Phone
Cellphone or Other
Is the applicant homeless?
Yes
No
If applicant is homeless, where are they living?
Is Parent/Guardian currently employed full-time?
Yes
No
In School Full Time?
Yes
No
PARENTS OF CHILDREN IN FULL DAY CHILD CARE MUST BE EMPLOYED, IN TRAINING and/or IN SCHOOL
What was your source of income for the previous 12 months or previous calendar year?
TANF SSI Employment Other, if other, describe:
Annual Family Income Amount?
Family Size?
(Family = People living in same household, supported by same income as applicant & related by blood, marriage or adoption)
Primary Language
How well does the person speak English?
Very well
Well
Not Well
Not at All
Does the applicant have a disability or special need?
Yes
No
if yes, describe below:
Is the applicant or parent pregnant?
Yes
No
If yes, due date
Place of Recruitment
Please indicate Applicant’s preferred center (circle one) Or closest location will be designated
Alexandria Drive (815) 730-8940
Felman Center (815) 727-5730
Good Shepherd (630) 783-2735
Rockdale/JJC (815) 280-2280
Broadway Center (815) 722-5353
Main Office (815) 723-3405 (Expectant Mothers)
Form Submitted by:
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