Head Start – Baltimore County

Baltimore County Head Start Referral Form 1

Select the service you are requesting: * Required
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Name of Child * Required
First Last
Child Date of Birth: * Required
MM slash DD slash YYYY
Does the child currently have an IEP or IFSP? * Required
- Yes,IEP
- Yes, IFSP
- No
Identified Child/Family Risk Factors: * Required
- Family member incarcerated
- Death or illness of Loved One
- Absence of parent
- Change in guardianship at any point in child's life
- Placement in foster care at any point in child's life
- None
Name of Parent/Guardian * Required
First Last
Relationship to Child * Required
Phone Number of Parent/Gaurdian * Required
Email of Parent/Gaurdian * Required
Name of Parent/Guardian
First Last
Relationship to Child
Phone Number of Parent/Gaurdian
Email of Parent/Gaurdian
What is the child's ethnicity?
Address of Child * Required
Street Address Address Line 2 City State ZIP Code
Parental Consent Packet
Max. file size: 63 MB.
Please upload completed and signed parent packet.
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What are the primary concerns? * Required
Site where service is needed: * Required
Address of Head Start Site: * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number at Site * Required
Lead Teacher Name * Required
First Last
Lead Teacher Email * Required
Early Childhood Coach Name (if applicable)
First Last
Coach Email
Zone Manager Name (if applicable)
First Last
Zone Manager Email
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Name of individual completing this request: * Required
First Last
Email of individual completing this request: * Required

19035

Baltimore County Head Start Referral Form 1

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