TALBOTCOUNTY EARLY HEAD START
REFERRAL FORM
215 Bay Street, Suite 1
Easton, MD21601
(410) 820-6940 Fax: (410) 820-6958
Referring Agency/ Department ______Worker ______
Telephone # ______Date ______
Child being referred ______
Child’s Birth Date ______Age ______Sex ______Race ______
Parent’s Name ______Date of Birth ______
Address ______
Home Phone ______Alternate Phone ______
STATUS:
Pregnant ______Due Date ______Marital Status ______
Estimated Family Income ______# of People in Household ______
Primary Language ______Secondary Language ______
Reason for Referral: (see reverse for program descriptions)
Early Head Start _____ Parents As Teachers _____ Parent Ed. _____ GED _____
English as a Second Language _____ Childcare _____Independent Study_____
Other Children in Home
NameAgeDate of Birth
______
Other Comments __________________
TALBOTCOUNTY EARLY HEAD START
REFERRAL FORM
215 Bay Street, Suite 1
Easton, MD21601
(410) 820-6940 Fax: (410) 820-6958
Early Head Start is a child development program for families with children from Birth to 3 years old. Early Head Start offers four program options for families, as well as a home visit only option for those who are unable to attend the center. Limited Child Care can is also available for enrolled families, though preference is given to teens who are enrolled in school. Schedules available for center-based participants are as follows:
Monday /Wednesday AM Program 9:00 – 12:30
Monday/Wednesday PM Program 12:00 – 3:30
Tuesday/Thursday AM Program 9:00 – 12:30
Tuesday/Thursday PM Program 12:00 – 3:30
Participants who are interested in enrolling will be screened for eligibility and put on the waiting list until a slot becomes available for their children. Transportation is available for enrolled families only.
Parent Education is offered at the Early Head Start center in the form of ongoing nurturing classes and family literacy programs. Please contact staff for more information.
Parents as Teachers is a home visiting program open to anyone in the community with children aged Birth-kindergarten entry or expectant families. PAT focuses on child development and parent education. There are currently openings in this program and will be filled on a first come-first served basis.
Adult Education classes and instruction are offered at the center weekdays. The schedule is as follows: Tuesdays and Thursdays9:15 to 11:00 and from 1:15 to 3:15. Evening classes may also be available through Chesapeake College Adult Education program.
English as a Second Language classes are also offered at the center. Instructors are available Mondays and Wednesdays from 9:15 to 11:00 and from 1:15 to 3:15. Structured classes are held daily, and are posted on our monthly calendar.
Please contact us to become part of our calendar mailing list
or with any questions or comments.
Thank you for your referral to our programs.
File in Family Record
Form Revised 8/4/09