Enrollment Form Part 3 – Pine Belt Head Start

Child Enrollment Form Part 3

PARENT/GUARDIAN INFORMATION

Please complete whether mother/father is in the home or not.

Single Parent (mother only)

Single Parent (father only)

Both Parents

Foster Parents

Other Relatives

Guardian

Grandparents

Other

Fathers Name

First Last

Date of Birth

Sex

Education Status

Employment Status

Occupation

Father Resides in the home

Father is the primary Custodial Parent of the child

Father is authorized to receive child

Are there court orders on Father

If the above is YES has a copy been provided to the center

Please fill out if Fathers address is different from child

Street Address

Address 2

City State / Province

Postal / Zip Code Country

Fathers Phone Number

Mothers Name

First Last

Date of Birth

Sex

Education Status

Enployment Status

Occupation

Mother Resides in the home

Mother is the primary Custodial Parent of the child

Mother is authorized to receive child

Are there court orders on Mother

If the above is YES has a copy been provided to the center

Please fill out if Mothers address is different from child

Street Address

Address 2

City State / Province

Postal / Zip Code Country

Mothers Phone Number

Guardian Name

First Last

Date of Birth

Sex

Education Status

Employment Status

Guardian Resides in the home

Guardian is the primary Custodial Parent of the child

Guardian is authorized to receive child

Are there court orders on Guardian

If the above is YES has a copy been provided to the center

Please fill out if Guardian address is different from child

Street Address

Address 2

City State / Province

Postal / Zip Code Country

Guardian Phone Number