Please enable JavaScript in your browser to complete this form.Child's Name *FirstLastPlease provide the name of the child regardless of whether they were previously enrolled.Cell Phone *(555) 555-5555Home Phone(555) 555-5555Email *How would you prefer to receive information from us? (check all that apply) *Phone CallVoicemailText MessageEmailWas your child an Early Head Start or Head Start student last year (2019-2020 school year)? *YesNoChild's Age *Please provide the child's age in years AND months (example: 3 years / 7 months)Question, Comment or MessageSubmit