Head Start (SDC-City-Wide) Pre-Application

Child must be three (3) years old upon first day of class
Date Completing Application:
Family Information *required fields
Parent/Guardian Name*:	Home Phone:
Address*:	Zip Code:
Mobile Phone:	Other Phone:
Child's Name*:	Child's Date of Birth*:
Email:
Child's Current Age as of date you complete this Pre-Application*:

How did you hear about SDC Head Start?
Does your child have special needs? Children diagnosed with disabilities are eligible for Head Start.
If yes, please specify your child's special needs:

Annual Income (before taxes):	Family Size:

Proof of information is required for enrollment in the Head Start program. All information is kept confidential unless its release is authorized in writing.
Alternative Contact
Name:	Relationship:
Address:	Home Phone:
Mobile Phone:	Other Phone: