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Thank you for considering Head Start education with Southeast Alabama Regional Planning and Development Commission! The child for which you are applying must be between the age of 3-5 years before an application can be submitted. If you submit an application for Head Start services, and this does not apply, your application will not be reviewed and will be considered incomplete. If your child has attended Early Head Start or Head Start, please STOP HERE. You do NOT need to complete the ON-LINE APPLICATION. You should contact the school with which your child is affiliated and up-date his/her information. Please complete with full the name of the participating child and PRIMARY adult. Please use date of birth using 00-00-0000 format. Current address and phone numbers are required.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender (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 (Required)

Opt In for Text Messages

Home Phone (Required)

Work Phone (Required)

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 (Required)

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language (Required)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent (Required)

Please complete with full name of the participating child and PRIMARY adult. Please use date of birth using 00-00-0000 format. Current address and phone numbers are required.

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

If you are married or your significant other resides in the home, please include them on the application. If they are listed, you MUST provide income for all working parties.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender (Required)

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.

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language (Required)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent (Required)

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Number in Household (Required)

Number in Family (Required)

Gross Annual Income (Required)

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

WIC ID (if applicable)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Is at least one parent/guardian an active duty member of the United States military? (Required)

Is at least one parent/guardian a veteran of the United States military? (Required)

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Primary Health Coverage (Required)

Insurance Number (Required)

Medicaid Eligibility (Required)

Medicaid Number

Doctor/Medical Home (Required)

Dental Coverage (Required)

Dental Coverage Number (Required)

Dentist/Dental Home (Required)

Does your child have a disability or do you have any concerns about your child's development? (Required)

Is there anything else you want to tell us about your child?

Potty-Trained? (Required)

List Size-Diaper/Pull-ups (Required)

Food Allergies? (Required)

Milk Allergies? (Required)

Environmental Allergies? (Required)

Specific Formula Needed?

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 for your interest in the Head Start/Early Head Start Program. Please click submit to finalize your application. We will contact you to set up an intake appointment. Please bring your proof of income, child's birth proof, and the child's insurance documentation.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings