Kokomo Center Schools HEAD START
Phone (765)454-7082 (800)497-0774
FAX: (765)454-7086
900 S. Goyer Road
Kokomo, IN 46901

HEAD START Application Request Form

Which County do you live in:

Today's Date:

Parent or Guardian Name:

Address:

City:

Zip Code:

Telephone Number:

Second Number:

Is it OK to leave a message on these phone numbers?

GENERAL INFORMATION

Child's Name

Age

Birthday:

Does your child have a diagnosed disability?

If yes, please describe

Has your child attended a Head Start program in the past?

If yes, where?

INCOME VERIFICATION

Total number of family members living in your home

Weekly Income:

Annual Income:

Do you receive TANF?

Do you receive SSI for any household members?

REFERRAL SECTION

Is this a referral from a community agency/partner?

If yes, please tell us the referring agency's name:

also, please tell us the person's name referring

Is this family High Risk?

Click Submit one time to send your request and the ERSEA clerk will be in contact with you., (Eligibility,
Recruitment, Selection Enrollment & Attendance).

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Serving Howard, Tipton & Miami Counties

Birthday: