Pre-Application for Early Head Start Enrollment

Today's Date *
Program Options *
Home-BasedFamily Child CareCenter Based- Full Day (Preschool Services with Child Care wrap around)Center Based- Half Day (Preschool Services 4 days / week)
If you selected Center-Based, center location:
CenterburgDanvilleFredericktownGambierMount Vernon

Mother's Full Name *
Mother's Date of Birth *
Father's Full Name *
Father's Date of Birth *
Physical Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Mailing Address (if differs from above)
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Primary Phone *
Secondary/Message Phone
Email
Number of Adults in Household *
Number of Children in Household *
Estimated Annual Income *
Please check the following that apply: *
SSIFoster ChildEmploymentTANF/OWFHomeless
Additional information: disabilities, medical, nutritional, or other issues: *
How did you hear about KCHS? Please check one: *
Phone BookWalk InKCHS Web SiteKnoxLink.orgRadioFriendFormer/Current Head Start ParentFormer StudentGRADSReferralNewspaper ad
Please list any siblings and their dates of birth:

Address: 790 Fairgrounds Road Suite 200
Mount Vernon, Ohio 43050
Office: (740) 397-1344
Email: [email protected]
[email protected]
[email protected]