Begin Enrollment at Semcac

Head Start

By completing this intake form it does not guarantee your enrollment. After completing the intake form and you have any questions, please contact the Semcac Head Start office in your county. A team member will be following up with each intake form to fill out an application.

"*" indicates required fields

Child's Name*

First Last

Child's Date of Birth*

Primary Caregiver's Name*

First Last

Primary Caregiver's Phone*

Primary Caregiver's Email*

Primary Caregiver's Address*

Street Address Address Line 2 City State ZIP Code

Primary language spoken in the home*

Will you need an interpreter?*

Yes

Head Start location you are applying for:*