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Early Head Start Enrollment Form

Please complete this form so that our early childhood team can contact you about getting started with our Early Head Start program:

"*" indicates required fields

Select date MM slash DD slash YYYY
Parent/guardian of an infant or toddler?
Child's name
Child's name
Child's name
Child's name
Adult’s Name
Relationship to Child(ren)
If Mother, are you currently pregnant?
MM slash DD slash YYYY
Check here if family identifies as homeless
Address
Does child's family receive:
Does your child have an active IFSP (Individualized Family Service Plan) from the Regional Center?
How did you hear about LAEP's Early Head Start program?
This field is for validation purposes and should be left unchanged.