Child:

First Name		MI		Last Name
Mailing Address
Street Name
City			State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip Code
Home Phone			Town of Legal Residence
DOB

Parent/Guardian:

Name			Name
Employer			Employer
Work Phone			Work Phone

One Person we may call to help reach you:

Name

Phone

Does your child have any special needs we should be aware of?

No

Yes, explain

Family Status

	Single parent
	Two parent
	Foster
	Other, explain

Number of children residing in the home 

What is your family's gross income?

Weekly

Monthly

or Yearly

Please indicate what type of program you are applying for.

	Full day Head Start/child care		Infant/toddler		Pre-school
	Part Day Head Start (3-5 year olds)

What location would work best for you?

	Augusta			Gardiner			Winthrop
	Pittston			So. Gardiner			Monmouth
	China			Readfield			Sidney

Signature of parent/guardian:

______________________________Date_______________