Lake-Geauga United Head Start, Inc.

Pre-Application

Date: Interviewer:

Center: Classroom Option: (Circle One) Am Pm Full Day Partnership

Parent(s): Relationship:

Child’s Name: If enrolling two children, please check here:

(Complete a separate application)

Address: Apt.:

City: State: County:

Phone #: 2^nd #:

Child’s D.O.B.: Age of Younger Sibling(s):

Best Times for Contact:

Annual Gross Income:

Additional Comments:

………………………………………………………………………………………………………………..

Method of Follow Up: Phone Mail Home Visit Center

Date Documentation

Result: Enrolled Denied Set Intake Appt. Waiting List Parent Not Interested

Date of Follow Up: Staff Signature: