OESD 114 Early Head Start / Head Start / ECEAP Program Inquiry Form Phone: 360.478.6889 Fax: 360.405.5808 Email: earlylearning@oesd114.org

Applicant (Child)
First (legal)	Middle	Last (legal)	Suffix	Nickname	Birthday	Gender
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap to enter a date.	☐ Male ☐ Female
Primary Adult (or Prenatal Applicant)
First (legal)	Middle	Last (legal)	Suffix	Birthday	Gender	Prenatal
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.	Click or tap to enter a date.	☐ Male ☐ Female	☐ Yes Approximate Due Date: Click or tap to enter a date.__________
Relationship to child: Click or tap here to enter text.	Interpreter Needed: Click or tap here to enter text. If yes, what language? Click or tap here to enter text.
Family Size: How many people live in your household? Click or tap here to enter text.

Family Contact Information
Email Address (required): Click or tap here to enter text.
Living Address	Address (include any apt. number)	City	Zip
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Family Mailing Address
Same as living? ☐ Yes ☐ No	Mailing Address (if different)	City	Zip
Click or tap here to enter text.	Click or tap here to enter text.	Click or tap here to enter text.
Phone Number(s)	Type (check one)	Opt In for Text Messages
Click or tap here to enter text.	☐ Cell ☐ Home ☐ Work ☐ Other Click or tap here to enter text.	☐ Yes ☐ No
Click or tap here to enter text.	☐ Cell ☐ Home ☐ Work ☐ Other Click or tap here to enter text.	☐ Yes ☐ No
Child/Family Information:
Child has an IEP/IFSP: ☐ Yes ☐ No	Concerns about child’s development: ☐ Yes ☐ No	Gross Annual Household Income: Click or tap here to enter text.
How did you hear about the program? Click or tap here to enter text.
Additional Information: Click or tap here to enter text.