Master Enrollment List

Fiscal Year:

Last Name

Month:

First Name

Date of
Birth

Licensed Capacity:

Attend
ed

Date of
Terminat
ion

Date of
IES
Determina
tion

Reimbursement
Eligibility Category
Reduc
Free
ed
Paid

Titl
e
XX

Hea
d
Star
t

1
2
3
4
5
6
7
8
9
1
0
1
1
1
2
1
3
1
4
1
5
1
6
1
7
1
8
1
9
Certification: The children indicated above are currently enrolled participants in the Head Start Program.
Authorized Head Start Representative Signature: ________________________________________
PAGE NUMBER: ________

Date:______________________

Civil Rights
Info
Ethnici
ty
Race

2
0
2
1
Totals:

Certification: The children indicated above are currently enrolled participants in the Head Start Program.
Authorized Head Start Representative Signature: ________________________________________
PAGE NUMBER: ________

Date:______________________