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Non Congregate Family Registration Form
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Non Congregate Family Registration Form
At Risk Sign In Page
Menu Toggle
At Risk Site Sign Up
Site Information
Head Start Page
Summer Program
Pre-Operational Visit Form
Senior Centers Meal Counter
Non-Congregate Family Registration Form
Non Congregate Family Registration Form
At Risk Sign In Page
At Risk Site Sign Up
Site Information
Head Start Page
Summer Program
Pre-Operational Visit Form
Senior Centers Meal Counter
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Non Congregate Family Registration Form
At Risk Sign In Page
At Risk Site Sign Up
Site Information
Head Start Page
Summer Program
Pre-Operational Visit Form
Senior Centers Meal Counter
Parent/Legal Guardian
Last Name
First Name
Legal Guardian Last Name
Legal Guardian First Name
Address
County
Phone Number
Child #1
DOB 1
Child #2
DOB 2
Child #3
DOB 3
Child #4
DOB 4
Child #5
DOB 5
Child #6
DOB 6
Child #7
DOB 7
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In accordance with civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (AD-3027) found online at : http://www.ascr.usda.gov/complaint_filing_cust.html and any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) Mail: U.S. Department of Agriculture Office of the Assistance Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410: Fax: (202)690-7442; or Email: program.intake@usda.gov This institution is an equal opportunity provider.
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