EHS Pre-Application Form

Date*

Today's Date

What Indiana county do you live in?*

Howard County
Miami County

Contact Information

Parent or guardian's name*

First Last

Email*

Address*

Street Address Address Line 2 City ZIP Code

Phone number*

General Information

Child's Name*

First Last

Child's Date of Birth*

Does your child have a diagnosed disability?*

Yes
No

If you answered yes to the above question, please describe*

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

Yes
No

If you answered yes to the above question, please tell us where*

Are any members of the household expecting?*

Yes
No

If you answered yes to the above question, please tell us who is the expectant individual and when is their due date*

Is the child in Foster Care?*

Yes
No

Income Verification

What is the total number of family members living in your home?*

*include expectant infants as 1

What is your weekly income?*

What is your annual income?*

Do you receive TANF (AFDC)?*

Yes
No

Do you receive SSI for any household members?*

Yes
No

Do you receive SNAP benefits?*

Yes
No

Was your family homeless at any time in the past twelve months?*

Yes
No

How did you hear about us?*

Referring Section

What is the name of the referring agency?

What is the name of the person referring?

Is this family High Risk?

Yes
No

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