Eligibility Application-- Please fill out this application completely and accurately. All information will be kept confidential. It will be used to help us determine if your family is eligible for Head Start or Child Care and to prioritize your placement on the waiting list. If you have any questions about this application, or need any help in completing it, please call 740-289-2371 ext. 7061 or send an email to headstart@pikecac.org. We will be glad to help!
Parent/Guardian
Please enter information about the primary adult. This is normally the mother or foster mother.
First Name (Required)
Middle Name
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.
SSN
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
American Sign Language
English
Hiligaynon
Spanish
Tagalog
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
Employed After Enrollment
Employed at Enrollment
Full-time & Training
Full-time (35 hours/week or more)
Lost job after Enrollment
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Self Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Address
Please list your physical living address. You may list a different mailing address below if needed.
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
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
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
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.
SSN
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
American Sign Language
English
Hiligaynon
Spanish
Tagalog
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
Employed After Enrollment
Employed at Enrollment
Full-time & Training
Full-time (35 hours/week or more)
Lost job after Enrollment
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Self Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Family Information
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
English
Hiligaynon
Spanish
Tagalog
Number in 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 from WIC?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Child (Applicant)
Please enter information about the child for which you are applying for Head Start or Child Care services.
First Name (Required)
Middle Name
Last Name (Required)
Nickname
Birthday (Required)
Gender
Female
Male
SSN
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
American Sign Language
English
Hiligaynon
Spanish
Tagalog
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Medicaid Number
Doctor/Medical Home
ABC Pediatrics Of Ohio/Dr Fitton
Adena Audiology
Adena ENT
Adena Family Medicine
Adena Family Medicine-Bristol Vi
Adena Family Medicine-Greenfield
Adena Family Medicine-Main Campu
Adena Family Medicine-Waverly
Adena Family Residency Clinic
Adena OB/GYN
Adena Pediatrics
Adena Pediatrics-Waverly
Adena Women's Health OB/GYN
Adena- Western Ave
Adkins, Kathleen-CNP
Ali, Mohammad-MD
Arnett, Carloyn-DO
Bautista, Mario-MD
Beam, Wayne- MD
Beam, Wayne-MD- (COPC)
Blake, Emily-Do-Adena OB
Blake, Emily-DO-Adena OB
Buckley, Christopher-DO-Adena OB
Bureau for Children with Medical
Bureau Of Service For Visually
CAC Community Empowerment
CAC WIC
Cappelletti, Danielle-MD
Caughlan, Bailey- CNP
Cedar Knoll
Chester Eye Center
Child and Adolescent Specialty
Children's Nationwide Hospital
Chillicothe Pediatrics (NCH)
Christ Care Pediatrics
Cincinnati Children's GI
Cincinnati Childrens -Ophthalmol
Cinncinati Children's Feeding Te
COVID School Food
Dayton Childrens Audiology Clini
Dayton Childrens Ophthalmology C
Ditraglia, John- MD
Early Intervention
Eastern Family Practice
Family Health Care-R. Williamson
Family Vision Center
Farinet, Catherine MD
Flinders, Amy- NP
Gabis, John- MD
Gilliland, Angela- CNP
Health Department (immunizations
Health Department car seats
Health Department other
Healthsource of Ohio-Hillsboro
Helping Hands Pediatrics
Highland Physicians for Women
Holzer Clinic -Pattonsville
Holzer Clinic Gallipolis
Hope Clinic
Hopewell Health Center
Howard, Scott-DO
Ironton Family Care Center
Jane-Wit, Kantima-MD
Jetty, Lois- MD
Kiddie West Pediatric Center
Lee, Jobeth-MD
Lopez, Ronald-MD Adena OB
Luckeydoo, Amy-MD Adena Pedi
Maranzana, Alex- MD
McCallum, Scott-MD-Adena Pedi
McNaughton, Amy- CNP
Mitchell, Marsha-CNP-Rocky Fork
Mizer, Richard-MD
Montavon, Greg-OD
Montavon, Gregory- OD
Moore, Angela-DO
Morehead, Scott, MD-Adena OB
Nationwide Children's Columbus
NCH (Pulmo)-Shell, Richard-MD
NCH Allergy and Immunology Dept
NCH Audiology Department
NCH Center for Autism Spectrum D
NCH ENT
NCH Eye Care (Ophthalmology)
NCH GI
NCH Medical Records
NCH Neurology
NCH Pulmonology/Asthma Program
Neff, Jill-DO
Ohio ENT & Allergy
Ortiz, Lilliam- MD
Oxley, Kimberly-MD
Pediatric Associates PSC
Pediatric Opthalmology Assoc
Penn, Ali CNP-VVHC
premier Women's Health
Primary Plus (Jerry Iery)
Radford, John-MD
Roberts, Jennifer DO (OBGYN)
Ross-Pike ESD
Runyon, Susan- FNP
Sever, Heather-DO
Smith, Laura-FNP
Smith, Matthew-MD
Smoking Ohio Quit Line
SOMC Eastern Family Practice
SOMC ENT Portsmouth
SOMC OBGYN Sandlin/Harris
SOMC Pediatrics
SOMC Pediatrics-Portsmouth
SOMC West Union Family Health
SOMC Western Family Practice
SOMC-West Union
SOMC-Western Clinic
Sullivan, Jon-MD
Tipton, Jill- CNP
Turjoman, Ahmed- MD
Turner, Cindy-OD
Urgent Care Adena
Urgent Care SOMC
Valley View Health Center - Wave
Valley View Health Centers
Villarreal, Richard-MD-Adena OB
VVHC porstmouth Dental
Walmart Vision Center-Hillsboro
YMCA - exercise
YMCA Membership for Kinship
Zidron, Amy-DO
Zile Family Health Care
Dentist/Dental Home
Alpha Dental
Aspen Dental
Beavercreek Pediatric Dentisty
Britton, William- DDS
Bullard, David- DDS
Burwinkle Family Dentist
CAC Community Empowerment
Chillicothe Family Dental
Chillicothe Pediatric Dentistry
Chris Hanners & Associates
Cinci. Children's Pedi Dentistry
Clark Family Dental-New ALbany
COA Center for Dental Wellness
Comfort Dental
Comfort Dental-Circleville
Complete Smiles Family Dentistry
CP Family Dental
CP Family Dental-Peebles
Davis Family dentistry
Davis, Stacy- DDS
Dublin Pediatric Dentistry
Fairfiled Family Dental
Family Dental Center-Chillicothe
Family Dental Center-Circleville
First Capital Dental
Frederick, Gohmann- DDS
Frost, Lisa- DDS
Greenfield Family Dentistry
Griffin, Ronald- DDS
Grove City Pedicatric Dentistry
Hanners, Chris-DDS
Hines Little Smiles Pedi Dentist
Holzer Dental Partners
Hopewell Health Center-Dental
Huntington Pediatric Dentistry
Infinite Smiles
Kelley, Paul- DDS
Lancaster Pediatric Dentistry
Little Smiles of Delaware
Magnolia Dental
Mandali, Bhupesh-DDS
Martin, David- DDS
McKnown, James- DDS
Murray, Tracy- DDS
Nationwide Childrens Dental Clin
Nelson, Robert-DDS
North Court Family Dentist
Nusbaum, Timothy- DDS
Peter Family Dentistry
PrimaryPlus-Dental Center
Scioto Smiles
Scott, Oliver- DDS
Shah, Marlena-DDS
Shawnee State Dentist
Slechter Dental Care
Southern Ohio Smiles
Springfield Pediatric Dentistry
Stonecreek Dental Care
The Grove Pediatric Dentistry
Tiny Teeth of Dublin
Upperman, David- DDS
Valley View Health Centers
Valley View-Jackson
Valley View-Portsmouth
VanZanten, Matthew- DDS
VVHC porstmouth Dental
Walls, Jarod- DDS
Williams, Brooke-Ironton Family
Winland, Roger-DDS
Wissler, Myers & Kallies Dental
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
EHS 2023-2024
HS 2023-2024
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 the Head Start Program. Please click submit to finalize your application. We will contact you to set up an intake appointment.
Required information is missing, see above.