Head Start/Early Head Start Interest Form

Questions marked with an asterisk (*) are mandatory. Do not leave blank. If not applicable, put "N.A".
Head Start/Early Head Start is a national child development program that serves income eligible families with children birth through five years of age and expectant parents. To be eligible for Head Start/Early Head Start, you must be a Fairfax County resident, meet the Federal Poverty Guidelines and your child must be between the ages of 0-5 years or you are an expectant parent. Please complete the Interest Form below so that your eligibility can be determined correctly. If you have any questions or to request this form in an alternate format, call the Office for Children Head Start Program, 703-324-8290 or TDD (Virginia Relay) 711.
1
* Parent/Guardian Information:
Full Name:
Birthday:
2
* Child Information:
Full Name:
Birthday:
3
* Please enter your living address:
Street:
City:
State:
Zip:
County:
4
Please enter your mailing address (if different than your living address):
Street/P.O. Box:
City:
State:
Zip: