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​For Community Agencies Only

To the Participating Agency:

Please use this form for any child that you are referring to Head Start as an ‘at-risk’ child. Fax the completed form, with a fax cover page to (209) 381-5172, ATTN: Family Services Manager.

Head Start staff will be contacting the family, using the contact information listed below, within the next two weeks.

If you have any questions as to the status of this family’s application or eligibility for services, please contact the Family Support Services Manager at (209) 381-5170.


Head Start Referral Form​ (downloadable .pdf)

Head Start Referral Form (online form)