Early/head Start Referral Form printable pdf download

EARLY/HEAD START REFERRAL FORM

Head Start and Early Head Start programs provide services for low-income families with children ages

birth to 5 years old as well as pregnant women at no cost. Early/Head Start programs enhance

children's physical, social, emotional, and intellectual development; assist pregnant women to access

comprehensive prenatal and postpartum care; support parents' efforts to fulfill their parental roles; and

help parents move toward self-sufficiency. Please use this form to refer families that may benefit from

these services. We will use the information provided to recruit eligible children for enrollment.

Child’s Name: __________________________________________________ Date of Birth: ________________

Mother’s Name: __________________________________________ Living with Child?

Yes

If pregnant when is the due date: _________ Is this person receiving prenatal services?

Yes

Father’s Name: ___________________________________________ Living with Child?

Yes

Home Phone#:_______________________________ Cell Phone#:_______________________________

Mailing Address: ________________________________________City: ________________Zip: ___________

Please indicate any/all programs in which the family is currently enrolled:

Medicaid

TANF

WIC

SSI

Foster Care

Families United

Early Intervention Colorado (Part C)

Community Infant Child Program (CICP)

Nurse Family Partnership

Community Child Care

Summit School District Preschool

Eligible families will be selected for enrollment in Early Head Start based on a variety of factors.

Please indicate any factors that you wish to be considered in the selection process below:

____________________________________________________________________________________________

By signing this document I affirm that I am authorized to provide Summit County Early / Head Start

with the personal information about the individual(s) listed above.

______________________________

_______________________________

______________

Referring Party Name

Signature of Referring Party

Date

__________________________________________________________________

Referring Agency Name and Contact Information

Early/head Start Referral Form