The following is an Interest form for Prime Time Head Start/ Early Head Start. Please have documents ready to upload in the required fields to successfully submit your interest. Further paperwork will be required, to be considered for enrollment.
Parent/Guardian
(Biological, Married, Adoption, Foster and /or Legal Assignment)
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender (Required)
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 (Required)
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
American Sign Language
Bengali
Dutch
English
German
Hindi
Laos
Nepali
Spanish
Spanish
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Disabled
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
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
Additional Parent/Guardian
Only complete this section if the Secondary Adult is currently living in the home, being supported by the same income and related by blood, marriage, or adoption.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
Other Language
American Sign Language
Bengali
Dutch
English
German
Hindi
Laos
Nepali
Spanish
Spanish
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Disabled
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Family Information
Number in household should include primary and secondary adults (if applicable) living in the home, and should include the applicant and additional children being supported by the same income, and related by blood, marriage, or adoption.
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
American Sign Language
Bengali
Dutch
English
German
Hindi
Laos
Nepali
Spanish
Spanish
Vietnamese
Is another language being acquired or learned at home?
Yes
No
Number in Household
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender (Required)
Female
Male
Race (Required)
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
American Sign Language
Bengali
Dutch
English
German
Hindi
Laos
Nepali
Spanish
Spanish
Vietnamese
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Doctor/Medical Home
A Pregnancy Center and Clinic
Abbeville Community Health Cente
Acadiana Hearing & Balance Ctr
Acadiana Sickle Cell Association
Affinity Pediatrics
Alexander, Lisa MD
All Kids Pediatrics of Opelousas
All Kids R Us Medical Clinic
Ascent Health Inc
Atwi, Jibran MD
Audubon Family Medicine
Avoyelles Pediatrics
Babineaux, Julie MD
Bailey, Brain MD
Bailey, Lauren, MD
Bares, George MD
Bastrop Pediatric-Communi Healt
Baton Rouge Pediatric Clinic
Baumbouree, Derek, MD
Bayou Family Care
Bayou Pediatrics LLC
Ben, Mia MD
Beslin, Tan MD
Boudreaux, Lynzie MD
Breaux Bridge Pediatric Group
Broussard Pediatric Group of Aca
Bruyninckx, Kyle MD
Bustillo, Mayra MD
Cadence of Acadiana
Cancer Survivors Acadiana
Carencro Pediatric Group of Acad
Chachere, Hannah MD
Chambers, Henrietta NP
Children Special Health Service
Children's Clinic of SWLA
Christy, Lawrrence MD
Clark, Stuart MD
Cocke, Kelli MD
Colvin Clinic
Cornerstone Pediatrics
Crowley Walk In Clinic
Daher Marlene
Dahr, Nahla M.D
Davuluri, Murali, M.D
Dawson, Marin MD
Degatur, Kate, MD
Derouen, Natalie MD
Diaz, Kathryn NP
Dr. Betty Aultman
Dr. Husam Sukerek, MD
Dr. Jennifer Levison
Dr. Kate Rugg, APRN
Dr. Lyndall Saadat-Kid Health
Dr. Michael Langiulli, MD
Dr. Nancy Zukowski
Dr. Sarah Dennison, MD
Dr. Shahzad M. Malik
Dr. Terri Sylvestri
Dupre, Henry, MD
Duronslet, Christie, MD
Duson Family HealthCare
Eason, Margot MD
East Carroll Medical Clinic
Eikel, Henry MD
Ent Of Acadiana
Epilepsy Task Force
Evangeline Optical
Eye Health Plus
Families Helping Families
Family Convience Clinic
Family Health Care Clinic
Family Medicine Center, UMC
Fleur De Lis Family Healthcare
Fontanez, Maria MD
Foster, Suzanne MD
Franklin Family Care
Franklin Foundation Hospital
Geaux Family Health
Gesn, Lois MD
Gonzales, Douglas MD
Gordon, Diane, CPNP
Grant, Shalini Reyna, MD
Great Beginings Pediatric
Gunda, Sharad, MD
Hardtner Medical Center
Hebert, Charice MD
Hernandez, Cary MD
Hidalgo, Colin, NP
Howes, Richard MD
Hurt, Erin APRN
Iberia Comprehensive Center
Iberia Medical Center
Iberia Parish Audiologist
Iberia Parish Pediatric Group
Iberia Pediatrics
Janga, Karunasri MD
Johnson, Carmen MD, FAAP
Jones, Tammy MD
Judice, Michael MD
Karani, Loreen MD
Kasindula, Ramakrishna MD
Kermen, Beauchamp MD
Kids Speciality Center
Korab, Yamen, MD
La Petite Pediatric Clinic
Lafayett Parish Health Unit
Lafayette Children's Clinic
Lafayette Eye Care
Lafayette General Hospital
Lafayette Pediatric Group
Lamar-Bellamy, Lawanda MD
Landry, Crystal NP
Lapite Family Medicine
Lavergne, Madelyn MD
Legacy Pediatrics
Legeune, Geneva MD
Lil Sprouts Pediatric Clinic
Lily Pad Pediatrics LLC
Lions Eye Foundation, Inc
Louisiana Rehabilitation Service
Lourdes Physician Group Pedi.
Lourdes Physicians Group @ Lafay
Luczak, Anthony MD
Madison Parish Health Unit
Mallory Middleton, NP
Manuel Medical Clinic
Marshall, Anecia MD
Maryanne Davis
Matthews, Dionna MD
McMurphy, Julie MD
Menina, Erica MD
Michael Brooks Family Clinic
Mitchell, Marcia, MD
Monroe Pediatrics-Communi Health
Morehouse Community Medical
Moss Street Kid Med LLC
Nervez, Cecili MD
Nguyen, Lisa MD
Nightengail Healthcare Resources
Northeast LA Health Center
Northside Community Health Cente
Nurse-Family Partnership
Oak Grove Medical
Ochsner University Hospital & Cl
Omaha Children's Clinic
Oschner LSU
Ouachita Parish Health Unit
Peach Tree Dental Ruston
Pediatric Associates of Lafayett
Pediatric Associates Of Monroe
Pediatric Clinic of Lafayette
Pediatric Group of Acadiana
Pediatric Group of Erath
Pediatrics Plus
Pensacola Pediatrics
Perkin, Camille MD
Pratt, Richard, MD
Preferred Pediatric Group
Premier Pediatrics Of Acadiana
Primary Health Pediatrics
Prime Time Staff
Progressive Pediatrics
PTHS Health Team-Ouachita
Qayyum, Tahir MD
Rader, Allison MD
Rayville Family Clinic
Richard, Piccione, MD
Ricks, Barrignton MD
Rito, Sarah MD
Rosales, J.P. MD
Saleme, Mary MD
Sandoz, Kristen MD
Sangisetty, Arunavathi MD
Scott Pediactric Group of Acadia
Scott, Walter MD
SD Hill Clinic
Shannon Brewer Pediatrics
Sherrie Drake, FPRN
Sibley, Bryan MD
Sicard, Collen MD
Sorrel, April MD
SouthCare Medical Center
SouthCare Medical LLC
Southside Pediatrics
St. Martin Community Action Ctr
St. Martin Community Health Ctr
St. Martin Pediatric Group
Sterlington Rural Health Clinic
Steven Ventures Family Medicine
Stuart, Landry, MD
Sugeng, Budi MD
Sunshine Pediatric & Family Clin
Surrey Street Community Center
SWLA Center for Health Services
Sylvester, Cynthia MD
Teche Action Clinic
Terrebonne Pediactrics Clinic
Texas Chidren's Pediatrics
The Pediatric Center
The Pediatric Clinic
Tots to Tassels Pediactrics
Toups, Lori MD
Tutu, Priscilla MD
UMC Family Medicine Clinic
University Health/Conway
Vasireddy, Deepa MB
Walter, Scott, MD
Washington Brandi, FNP
West Carroll Medical Clinic
West Monroe Pediatrics
Williams, Gerard MD
Women and Children Hospital
Yerasi, Srinivasa MD
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dentist/Dental Home
Abbeville Community Health Cente
Acadiana Pediatric Dentistry
Affordable Dental
Apple Dental
Arrow Dental
Babineaux Family Dentistry
Bayou Braces and Denistry
Bayou Childrens Dental Center
Bayou Dental Group
Benjamin, Tasha DDS
Bercier Family Dentistry
Bercier III, Edwin DDS
Beverly, Kredenna DDS
Broussard, Charles DDS
Brown, Kennell DDS
Bumgardner, DDS
Bunkie Dentistry
Burke, Brittaney
Caldwel, Kimberly DDS
Castle, Harry DDS
Clark, Shelly DDS
Collins, Latedra DDS
Dejean, Seth DDS
Dr. Betty Aultman
Fontenot Family Dentistry
Fontenot, Jade, DDS
Franklin Foundation Hospital
Gardener, Chad DDS
Giggles And Grins Family Dentist
Guedry, Kelly DDS
Guedry, Kelly DDS
Guilbeau, Kenneth DDS
Gunda, Sharad, MD
Heath, William DMD
Henagan Dentistry
Hendry & Associates, John DDS
Holmes, Antonia DDS
Iberia Comprehensive Center
Iberia Parish Pediatric Group
Iberia Pediatrics
Jacobs, Leslie DDS
John Snuggs Pediatric Dentistryy
Keaty & Gouri Pediatric Dentistr
Keaty, William MD
Kids Dental Zone
Kincade, Monica DDS
Kool Smiles
Lafayett Parish Health Unit
Lafayette Pediatric Dentistry
Lafayette Pediatric Group
Little Cassis Dental
Lorio, Michael DDS
Louisiana Dental Group
Lourdes Physician Group Pedi.
Lourdes Physicians Group @ Lafay
Maestri, Gina DDS
Manuel, Charles DDS
Melancon Family Dentistry
Meridith, Mark DDS
Miliken Family Dentistry
Monroe Family Dental
Monroe Pediatrics-Communi Health
Morgan Family Dentistry
NELA Dental
Northside Community Health Cente
Noto, Hannah B, DDS
Oak Park Dental
Omaha Children's Clinic
Omega Dentistry
Omni Dental Center
Park Pediatric Denistry, LLC
Patel, Sapna, DDS
Peach Tree Dental Monroe
Peach Tree Dental Ruston
Peach Tree Dental Ruston
Peach Tree Dental WM
Pediatric Dentistry of Natchitoc
Pelican Pediatric Dentistry
Pensacola Family Dental
Primary Health Dental
Prime Time Staff
PTHS Health Team-Ouachita
Quest Pediatric Dentistry
Ragusa, Laureen, DDS
Rider Dental
Ritter, Melissa, DDS
Roots Pediatric Dentistry
Sanders, Brett MD
Smiles Star Pediatric Denistry
Snaggle Dental
Sommers, Anne DDS
Southern Family Dental
Southern Roots Dental
Southern Smiles of Iberia
Southern Smiles-Rayville
Southwest Louisiana Primary
St. Martin Community Action Ctr
St. Martin Community Health Ctr
St. Martin Pediatric Group
Stratton Jr., Ronald DDS
Surrey Street Community Center
SWLA Center for Health Services
Tarver, Justin DDS
Taylor Dental
Taylor Dental
Teche Action Clinic
Ted, Ardoin DDS
Texas Chidren's Pediatrics
Theriot Family Dental Care
Tiger Paw Dental
Tim Chauvin DDS & Associates
Tim Chauvin, DDS & Associates
Toups Family Dentistry
Tuft Pediatric Dentistry
Twinkling Smiles Dental
UniTech Training Academy
Vintage Dental
West Carroll Medical Clinic
West Monroe Pediatrics
Williams, Yolanda DDS
Willie, Collins DDS
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Location Preferences
Which program are you applying for? (Required)
Early Head Start 2025-2026 School Year
Children Ages Birth to 3 years old
Head Start 2025-2026 School Year
Children Ages 3-5 years old
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
You will receive an email confirmation once the application is submitted. We will contact you within 14 days to schedule an appointment to complete the registration process.
Required information is missing, see above.