Head Start Directory

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Head Start Pre-Registration Form

WAYNE COUNTY HEAD START
30712 Michigan Avenue
Westland, Michigan 48186
734-727-7620
Date
[mm-dd-yyyy]:
Local School District:
Parent’s First Name:
Parent’s Last Name:
Daytime Telephone Number [xxx-xxx-xxxx]:
Evening Telephone Number [xxx-xxx-xxxx]:
Child’s Address:
City:
Zip Code:

Major Intersection near address:

Child’s First Name:
Child’s Last Name:
Child's Birth Date
[mm-dd-yyyy]:
Do you have a child currently enrolled in Head Start?

If yes, what site does your child currently attend?

Estimated family income for the last 12 months:
Is your income from:
Number of persons in family:
Do you receive Child Care Reimbursement from FIA?

Does your child have any disabilities or special needs? If Yes, explain:
How did you hear about Head Start?

When you submit this form, someone from Head Start will contact you to complete the application process.

Do you want to be contacted at:

Email address:

THANK YOU FOR VISITING THE WAYNE COUNTY HEAD START WEB SITE