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*
MM slash DD slash YYYY
Primary Caregiver's Name*
Primary Caregiver's Address*
Will you need an interpreter?*