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C.E.F.S. Economic Opportunity Corporation

1805 South Banker Street

Effingham IL 62401

217.342.2193

Head Start Child Referral

The CEFS Head Start 0-5 Program only provides services to children and families in the following Illinois counties: Christian, Clay, Effingham, Fayette, Montgomery, Moultrie, and Shelby.

Referring agency and/or provider name

Name of Contact Person

Phone

By providing a telephone number and submitting this form, you agree to receive information messages (appointment reminders, account notifications, etc.) from C.E.F.S. Economic Opportunity Corporation. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at cefs@cefseoc.org. You can opt out at any time by replying STOP.

Fax

Email

Child's Information

Child's name

Date of birth

Parent/Guardian Name

Parent/Guardian Phone

Address

Reason for referral

C.E.F.S. Economic Opportunity Corporation

1805 South Banker Street PO Box 928

Effingham IL 62401

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