Apply Online

Please fill out all information in order to get your application started. Staff will be contacting you within one week to get the rest of your information.

If available, please use the mother of the child as the primary adult unless she is not living in the home.

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

Email Address (Required)

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Opt In for Text Messages

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

SSN

Race

Hispanic

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Please complete the following information

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

Click here to find a provider in your area.

Mailing Address same as Living Address

Mailing Address

Address Line 2

City

State

ZIP

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

Email Address

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Opt In for Text Messages

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race

Hispanic

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Are there other adults in the household?

Add Another Adult

please complete the following information. We will need a copy of your tax information, W2's, or any other income you may have in your household. We will be contacting you shortly for this information. Regarding your emergency contacts, you as parents or guardians will always be contacted first. These extra contacts can be grandparents, aunts/uncles, friends, etc. Please check whether we can contact them in case of an emergency AND if we have permission to release the child to them

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Number in Household

Number in Family

Gross Annual Income

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

Add Emergency Contact

Under the disability section - this is a child that is currently working with the Area Education Agency and has an IFSP or IEP

First Name (Required)

Last Name (Required)

Nickname

Birthday (Required)

Gender

SSN

Race

Hispanic

Other Language

Primary Health Coverage

Other Coverage

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dentist/Dental Home

Does your child have a disability or do you have any concerns about your child's development?

Is there anything else you want to tell us about your child?

Which program are you applying for? (Required)

Location Preference

1st Location Preference

2nd Location Preference

3rd Location Preference

- Your Address - Available Locations

Click a location on the map to see more info

Click here to find a provider in your area.

Do you want to apply now for another child in your family?

Add Another Applicant

Are there other children in the family?

Add a Sibling

Thank you for your interest in the Early Head Start, Head Start or CDC programs. Please click submit to finalize your application. We will contact you to set up an intake appointment.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings