Appointment/Information Request

1. Appointment/Information request (updated 8/30/18)

Agency staff will follow up for an appointment.

Head Start is a FREE child care & pre-school program for children between the ages of 0-5 years old as of 09/01 for a program year. There is no potty training requirement to attend this program (except Sycamore site).

We have immediate openings in the 0-35 months Home Base program. (8/30/18)

We have immediate openings for 3's and 4's at 375 Lake Blvd. and 1926 Sycamore (must be potty-trained for Sycamore).

All children must be up-to-date on their immunizations for a center-based Head Start program.

For more information please visit the following website: http://www.shotsforschool.org/laws/exemptions

We are currently accepting applications for program year 2018/19.

Eligibility is based on federal income poverty guidelines; TANF/CalWORKS recipients; Foster Care; McKinney Vento (Homelessness). Children with diagnosed disabilities are acknowledged as having a priority.

*2018/19 Expected start dates: Part day HS (ages 3&4) classes start 8/15/18. Early Head Start & State full day are year round and continuously enrolling. Expected State start date is 7/6/18.

Please take the following survey to help us better address your questions.

Thank you, Shasta Head Start Child Development Inc.

Question Title

* 1. How did you hear about us?

Radio

Newspaper

Magazine

Friends/Family

Referring Agency

Other (please specify)

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* 2. How may we contact you?

Parent/Legal Guardian: *

Referring Agency:

Living Address:

Mailing Address if different:

City/Town: *

State:

Email Address: *

Phone Number: *

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* 3. Is this an updated address/phone#?

Yes

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* 4. Zip Code

Other (please specify)

Question Title

* 5. What type of information are you looking for?

	Yes	No
Place child on Waitlist	Place child on Waitlist Yes	Place child on Waitlist No
Update information on Waitlisted child - Not currently receiving services	Update information on Waitlisted child - Not currently receiving services Yes	Update information on Waitlisted child - Not currently receiving services No
Update information on Enrolled child - Currently receiving services (this includes children on summer break)	Update information on Enrolled child - Currently receiving services (this includes children on summer break) Yes	Update information on Enrolled child - Currently receiving services (this includes children on summer break) No
Center Hours & Locations	Center Hours & Locations Yes	Center Hours & Locations No
Description of how program works	Description of how program works Yes	Description of how program works No
Community Referral	Community Referral Yes	Community Referral No

Other (please specify)

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* 6. Exit - Staff will contact you to set up an appointment.

Yes

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* 7. STAFF only: Follow-up

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