Enrollment Form 1 Child Enrollment Form Part 1 You must complete Parts 1-2-3 of the Enrollment Form Applicant Name: First Last Middle Name: Race: Black/African American White Hispanic/Latino Asian Biracial/Multiracial American Indian Vietnamese Other Gender: Female Male Date of Birth: Address: Living Mailing Pick up Drop Off: City/Town State: Zip Code Home Phone Number Cell Phone Number Child previously enrolled in Head Start No Yes If above is YES please check the following: 1st Yr. 2nd Yr. Early Head Start Head Start Base What language is spoke at home? English Spanish Other What language do you (parent/ guardian) prefer to communicate in? English Spanish Other If you're not a fish leave this field blank: