Head Start Intake Form

Parent Information

Parent Name
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Area
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State
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CCRC does not cover any service area outside of the San Fernando and Antelope Valleys. If you live in an area not served by one of our locations, click here to find more Head Start preschools.

Zip Code
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Site Preference
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Site Preference
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Site Preference
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Site Preference
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Site Preference
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Email
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Phone Number
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Best Time To Call
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Best Way to Contact You
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Language
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Child Information

Child's Name
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Child's Birthday
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Is a Foster Child
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Would you like to enroll another child?
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Has an IEP or IFSP
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Other

Referred By
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Are you or any Family member currently employed by CCRC?
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Do you or your family members receive the following services/payments:

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By submitting this form you are acknowledging that the information provided is factual and that you understand that this does not guarantee wait listing or enrollment.

Child Care Resource Center

SAN FERNANDO VALLEY

20001 Prairie Street
Chatsworth, CA 91311

818.717.1000

Monday: 8:00 am – 7:00 pm
Tuesday - Friday: 8:00 am - 5:00 pm

ANTELOPE VALLEY

250 Grand Cypress Avenue
Palmdale, CA 93551

661.789.1200

Monday: 8:00 am – 7:00 pm
Tuesday - Friday: 8:00 am - 5:00 pm

SAN BERNARDINO

1111 East Mill Street, Suite 100
San Bernardino, CA 92408

909.384.8000

Monday - Friday: 8:00 am - 5:00 pm

VICTORVILLE

15456 West Sage St
Victorville, CA 92392

760.245.0770

Monday - Friday: 8:00 am - 5:00 pm