Please fill in the application form completely and accurately. If you have ever filled out an application in the past, please stop and call 541-323-6543. The information you provide will help us determine your child’s eligibility for Head Start / Early Head Start and help us prioritize your application. This application is part of an intake process and does not guarantee enrollment into the program. All shared information will be held in strict confidence. If you are uncomfortable completing any part of this application, have questions about your eligibility, or would like to discuss your situation with a staff member, please contact Dawn Adams, Family and Community Partnership Coordinator at 541-323-6543. To qualify for services your child must be 3 or 4 years old on or before September 1st of the year you are applying. Intentionally falsifying information to gain program enrollment may result in your child not being allowed to participate in Head Start or Early Head Start programs.
Parent/Guardian
Please provide as much information as possible if you have any questions or concerns please call 541-323-6543
First Name (Required)
Last Name (Required)
Nickname
Birthday (Required)
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
White
Hispanic
Yes
No
English Proficiency (Required)
Little
Moderate
None
Proficient
Other Language
American Sign Language
Chinese
English
Native American Languages
Other
Russian
Spanish
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
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
Includes adults who are related by blood, marriage, or adoption and are living within the same household as the child applicant.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Decline
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.
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Family Information
Head Start must know how many people are living in your household and the total family income in order to determine if your family income is at or below the Federal poverty guidelines. Family is defined for our purposes as “all persons living in the same household who are supported by the income of the parent(s) or guardian(s) of the enrolling child and are related to the parent(s) or guardian(s) by blood, marriage, or adoption.”
Number of Parents/Guardians
One Parent Family
Two Parent Family
Gross Annual Income
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)
Last Name (Required)
Nickname
Birthday (Required)
Gender
Decline
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
White
Hispanic
Yes
No
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)
EHS 2023-2024 school year
Home based or Center Based program for pregnant mother's and children 0-3years
Head Start 2023 - 2024 School year
Preschool for children ages 3 to 5
Head Start 2024 - 2025 school year
Preschool for children ages 3 to 5
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 your interest in NeighborImpact Head Start / Early Head Start. If you have questions or have not received a response to your application within seven days, please call 541-323-6543.
Required information is missing, see above.