Please complete the form below to begin your application process for the Head Start Program with Easterseals Early Learning Services. Please be sure to provide current and accurate information regarding your child and family, as this will ensure the application process goes as quickly as possible. Completing this form is the first step in the application process. A member of our team will be in contact with you after your interest form is submitted. If you need to speak with a staff member sooner or have an urgent matter, please cal 331-264-4295 Monday - Friday between 8:00 AM - 4:00 PM.
Parent/Guardian
The primary adult must live in the home with the child applicant.
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
Yes
No
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
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Languages
American Sign Language
Arabic
Caribbean Languages (Haitian-Creole, Patois))
Chinese-Cantonese
Chinese-Mandarin
Chinese-Taishanese
English
French
Italian
Native Central American, South American & Mexican Languages
Other
Other European & Slavic Languages
Polish
Spanish
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Address
Is your family experiencing homelessness?
Yes
No
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
Family Information
Primary Language at Home
African Languages
American Sign Language
Arabic
Caribbean Languages (Haitian-Creole, Patois))
Chinese-Cantonese
Chinese-Mandarin
Chinese-Taishanese
English
French
Italian
Native Central American, South American & Mexican Languages
Other
Other European & Slavic Languages
Polish
Spanish
Is another language being acquired or learned at home?
Yes
No
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Languages
American Sign Language
Arabic
Caribbean Languages (Haitian-Creole, Patois))
Chinese-Cantonese
Chinese-Mandarin
Chinese-Taishanese
English
French
Italian
Native Central American, South American & Mexican Languages
Other
Other European & Slavic Languages
Polish
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Location Preferences
Which program are you applying for? (Required)
New School Year 2024-25 Suburban Ages 0-2 yrs
Full Day Early Learning in centers or Home Visiting 1 time per week for pregnant moms and children 0-35 months
New School Year 2024-25 Suburban Ages 3-5 yrs
Full Day Early Learning in centers or Home Visiting 1 time per week for pregnant moms and children 0-35 months
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
Are there other children in the family?
Add a Sibling
Thank you for submitting a pre-application for Easterseals Early Learning Services. This is the first step of the application process. If available, please upload your child's birth certificate, income documentation, physical, and dental in the application link. Our intake team is awaiting the opportunity to speak with you. Please call 331-264-4295 Monday - Friday between 8:30 AM - 4:00 PM. We look forward to speaking with you within the next 2 business days.
Required information is missing, see above.