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Welcome future Early Head Start and Head Start Parents! The Early Childhood Programs at Ross County Community Action Commission Inc. provide services to prenatal women through children age 5! This application is the first step in the enrollment process; please fill out the information below to the best of your ability. If you have "shared custody" then income documentation from both parents is required. APPLICATIONS ARE NOT CONSIDERED COMPLETE AND CAN'T BE FULLY PROCESSED UNTIL PROOF OF INCOME HAS BEEN PROVIDED AND AN INTAKE APPOINTMENT COMPLETED. Income documentation can be uploaded as part of the application, if you do not have the documentation available now then you may return to the application and upload it later. If you have any questions, please contact our main office at 740-702-7222 ext. 115 or ext. 118.

Please provide as much of the required information as you can. The primary adult is the adult that is the residential custodian of the child; if the parents are married then either adult can be listed as the primary adult. There is an opportunity to list additional parents/guardians further down the page.

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

Lives with Family

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Teen Parent

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

Only complete this section if the Secondary Adult is currently living in the home, being supported by the same income and related blood marriage or adoption.

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.

SSN

Race

Hispanic

Lives with Family

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Teen Parent

For TANF, SSI, WIC or SNAP only answer 'Yes' if you are currently receiving those benefits. Proof of Income and copies of awards letters will be requested.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Household

Number in Family

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?

WIC ID (if applicable)

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?

Please complete this information about the child you would like to enroll.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

SSN

Race

Hispanic

Other Language

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

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 so much for your interest in our Early Childhood Programs. You will be contacted by our Enrollment Manager to set up an intake appointment. APPLICATIONS ARE NOT CONSIDERED COMPLETE AND CAN'T BE FULLY PROCESSED UNTIL PROOF OF INCOME HAS BEEN PROVIDED AND AN INTAKE APPOINTMENT COMPLETED. Income documentation can be uploaded as part of the application, if you do not have the documentation available now then you may return to the application and upload it later. If you have not heard back within 7-10 business days, please contact Ross County Community Action at 740-702-7222 ext. 115 or ext. 118.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings