Application

Registration/Application for Culpeper County Schools and Early Head Start

To All Applicants:

Culpeper Human Services/Kid Central/Early Head Start is a federally funded program serving infants and toddlers under the age of 3, and pregnant women. Early Head Start provides early, continuous, intensive, and comprehensive child development and family support services to low-income infants and toddlers and their families, and pregnant women and their families. For more information call: 540-829-2330

Please complete and return the following application.

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1
Child's Namefull name
Date of Birthmm/dd/yyyy
Sex
Expecting Mother
Due Datemm/dd/yyyy
Addressinclude ZIP
0 /
Elementary School District
Child lives with
If other, explain
0 /
Parent/Guardian Information
Mother's Nameparent/guardian
Date of Birthmm/dd/yyyy
Addressif different from the child
0 /
Home Phonemother
Work Phonemother
Cell Phonemother
Mother's Employer
Highest Level of Education Completedmother
Father's Nameparent/guardian
Date of Birthmm/dd/yyyy
Addressif different from the child
0 /
Home Phonefather
Work Phonefather
Cell Phonefather
Father's Employer
Highest Level of Education Completedfather
Personal Information
Does your child have an IEP (Individualized Education Plan) with the school system?
Does your child have a physical disability?
Does your child speak English?
Does the parent/guardian have any serious health related needs?
Do you have a Social Worker or Public Heath Nurse?
Have any of your other children been enrolled in child care/preschool?
If Yes, name of school?
Are you presently receivingselect all that apply
Household Residenceselect all that apply
If Other, explain
0 /

Household Profile

Please list all individuals who live in the home–including the child, child's parent(s)/guardian, siblings, and other individuals living in the home.

Parents' Annual Income
Others in HouseholdList names, date of birth, relationship to child, and income if applicable
0 /

The program may reach out to parent through social media in the event that our contact information is not updated. 

Signaturefull name of person filling out application
Today's Date
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1401 Old Fredericksburg Rd
Culpeper, VA 22701

540 829-2330

540 829-2057

reception@culpeperhumanservices.org

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