Welcome to the NICAA Head Start online application!Please fill out all information listed below. If you have any questions feel free to contact the NICAA Head Start office at (815)235-3740.
Parent/Guardian
First Name (Required)
Last Name (Required)
Suffix
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
Lives with Family
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African
American Sign Language
Arabic
English
Spanish
Vietnamese
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
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Teen Parent
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.
Additional Parent/Guardian
Please complete with area if the child lives with more than one parent/guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
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.
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
Lives with Family
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African
American Sign Language
Arabic
English
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
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Family Information
Please fill out all areas.
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
African
American Sign Language
Arabic
English
Spanish
Vietnamese
Number in Household
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
Emergency Contacts
Add Emergency Contact
Child (Applicant)
First Name (Required)
Last Name (Required)
Suffix
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
African
American Sign Language
Arabic
English
Spanish
Vietnamese
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
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
Doctor/Medical Home
Abby Allen
Adkins, Kristina
Ali
angela rodriguez
Angelilli, Adam
Ashkef
Au
Barbon
Bennett, Brian
Bennett, Diann
Bluemel
Callaway
Carina Elgar
Carlson
Child Find Screenings
Cottage Medical Center
Crescent
Crusader Clinic
Davis
Dr. Eric Gale
Dr.Micheal Muise
Duemler
Dysard, Tracy
Erie Humboldt Park Health Center
FHN
FHN Speech/Occupational Therapy
Frey
Friend Family Health Center
Fulton, Z.
Galena Grade School
Galena Health Clinic
Grand River Medical
Guffey
Gunderson Clinic
Hart
Hay, V.
Hornbach
Ignatio Omengun
Jackson, RaeLynn
Jelinek
Johnson
Julan Crane
Kevin Fransen
Kori Barry
Lawndale Christian Health
LuAnn Jordan
Ludwig
Martinez
Mary Koeing
McDonald, B.
McFadden
Medical Associates
Mercy Health
Merry
meyers
Michael Kelly
Midwest Health Clinic
Miller, A.
Miller,T.
min nguyen
Monroe Clinic
Mustafa, A.
Olberding
OSF
Owens, R.
Pandian
Parekh
Parks
Pederson
Perryville Family Practice
Peterson
PIC
Reese, David
River City Family
Riverside Medical
Robyn
Ruldolph
Sandra Jackson
SCHD Community Clinic
Schleich, Jeffrey
Shriver, Rebecca M.S. CCC-SLP
SIHF
Steven Zenker
Tawfik, S
Teji
Terry Miller
Thomas
tiffany kuhlmeyer
Tracy Clay FNP
tri sate medical
UW Health
Vandigo
Wells
Westside Health Center
Workman
Zahn-Hauser
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dental Coverage Number
Dentist/Dental Home
Awender
Bart
Chorak
Crusader Clinic
Crusader Clinic
LCHO
Neumeister, J.R.
Orland Park
Park City Dental
Paul
Reedy
Sandra Jackson
SCHD
smile dental mobile
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)
Head Start
Free Preschool
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 NICAA Head Start Program. You will be contacted to set up an interview and verify any income you may receive. There will be additional paperwork to be completed as well. Please click submit to finalize your application. We will contact your to set up an intake appointment.
Required information is missing, see above.