Department of Health & Human Services

Head Start Group

Head Start Pre-Registration Form

Wayne County Head Start
30712 Michigan Avenue
Westland, Michigan 48186
(734) 727-7620

Parent’s First Name:    Parent’s Last Name: Local School District:

Daytime Telephone Number:    Evening Telephone Number:


Child’s First Name:    Child’s Last Name: Child’s Date of Birth:


Do you have a child currently enrolled in Head Start?
If yes, what site does your child currently attend?

Child's Address    City State Zip Code

Major Intersection Near Address:

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

City Zip Code


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

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

Department Organizations...

Cecelia Mobley
Head Start Director

KAY BEARD BUILDING
30712 Michigan Avenue
Westland, MI 48186

1-866-534-KIDS(5437)

Welcome to Wayne County, Michigan

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Department of Health & Human Services

Head Start Group

Head Start Pre-Registration Form

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