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Blue Valley Community Action

Head Start 0-5 Application

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A
Income Source
B
Amount Annually
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A
Income Source
B
Amount Annually
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A
Adult/Child
B
Last Name
C
First Name
D
Birthday
E
Gender
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A
Name
B
Phone
C
Relationship
D
Contact in Emergency?(y/n)
E
Release to? (y/n)
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Based on the family situation, we may request additional documents as needed.

Staff will be in contact with you soon to follow up on your application.  Feel free to contact staff at the center if you have any additional questions.


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