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? (Required.)

Radio

Newspaper

Magazine

Friends/Family

Referring Agency

Other (please specify)

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2. How may we contact you? (Required.)

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 (Required.)

Other (please specify)

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5. What type of information are you looking for? (Required.)

	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

Continue

Stop

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* 1. How did you hear about us? (Required.)

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* 2. How may we contact you? (Required.)

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

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* 4. Zip Code (Required.)

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

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

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* 7. STAFF only: Follow-up

1. How did you hear about us? (Required.)

2. How may we contact you? (Required.)

3. Is this an updated address/phone#?

4. Zip Code (Required.)

5. What type of information are you looking for? (Required.)

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

7. STAFF only: Follow-up