McIntosh Trail Early Childhood Development Council, Inc.

Early Head Start * Head Start Preschool * Pre-K Application

Serving 7 Counties: Butts, Henry, Lamar, Newton, Pike, Spalding, and Upson County

Central Office

565 Recreation Drive ~ Jackson, GA 30233

Phone: 770-775-4293 ~ Fax: 770-775-1114

FRAUD WARNING: PARTICIPANTS WHO INTENTIONALLY COMMIT FRAUD ON INCOME INFORMATION MAY SUFFER LEGAL CONSEQUENCES OF ARREST OR FINES AND REMOVAL FROM THE PROGRAM

Before your application is processed the following information should be included.

1. Verification of income (W-2 form, pay stubs, child support, and TANF statement, letter from employer, SNAP letter)

2. Certified copy of birth certificate

3. Immunization certificate (Form 3231)

4. Copy of Medicaid/Peach Care, or Private Insurance card

5. If child is in Foster Care, copy of letter

Child's Information

Child’s Last Name

Child’s First Name

Gender

Male

Female

Ethnicity

If biracial/multiracial, please specify below

Child's Birthday

Month

Day

Year

Child's Age

Cell Phone

Home Phone

Address

Country/Region

Address

City

Zip / Postal code

Household Information

Father's Last Name And First Name

Father's Mailing Address

Country/Region

Address

City

Zip / Postal code

Father's living address, complete if different from mailing address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Father's Employer

Father's Employer Address

Father's employer's address

Country/Region

Address

City

Zip / Postal code

Job Title

Race

Father's Birthday

Month

Day

Year

Employment Type