Head Start/Early Head Start Contact Form

Please note: Submitting this form only STARTS your application and registration process. Additionally, it does NOT place your child on an enrollment waiting list. Further steps, such as speaking with a Child Care Parent Counselor and submitting required information, must take place before your child is registered and considered for enrollment.

During the months of July and August, our staff is in training. Please go ahead and submit your information. We will respond during the first week of September. Thank you for your patience and understanding. If your child turns four-years-old on or before August 31, 2016, please call 336.369.5097. Thank you!

Your Information

Morning
Afternoon
Evening
Weekday
Weekend
Email
Home Phone
Work Phone
Cell Phone

Please list the birthdates of any children you wish to enroll.

* Required information