Beaufort Jasper EOC Head Start

Family Communication Form

Child(s) First Name:*

Child(s) Middle Name:

Child(s) Last Name:*

Parent(s) First Name:*

Parent(s) Middle Name:

Parent(s) Last Name:*

What program option are you registering for?*

Center:*

Primary Phone:

Home Phone:

Work Phone:

Text Messaging Consent
There may be times throughout the year that Head Start would like to send a brief text message to parents (i.e. event reminders, center information, family service information, etc.). Since text messaging is not free; parents who want to receive texts must complete the information below giving permission.

Yes, I want to receive text messages from my child's Head Start center to the mobile number indicated above.

No, I do not want to receive text messages at this time.

Address:

City:

State:

Zip Code:

Email Address:*

Yes, I want to receive emails from my child's Head Start center. I have provided the email address above.

Emergency Contact Information:

Name:

Relationship:

Phone #:

Name:

Relationship:

Phone #:

Name:

Relationship:

Phone #:

I confirm that I have read and understand this form. *

By checking this option, I choose to manually sign this form.

By checking this option, I prefer to have the system electronically sign this form for me.

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Parent Signature

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