Please call 401-367-2001 or email at headstartenrollmentinfo@ebcap.org if you are not able to complete this on-line application. East Bay Community Action Program serves all eligible residents, regardless of their gender, age, race, or income status.
Parent/Guardian
Please complete the following for the primary adult.
First Name (Required)
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.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Unspecified
White
Hispanic
Yes
No
Other Language
Akan language
American Sign Language
Arabic
Bangla/Bengali
Creole
Dari
Deutsch
English
French
Georgian
Gha
Gujarati
Hebrew
Hindi
Italian
Japanese
Khmer
Korean
Laotian
Malay
Malayalam
Mandarin
Nepalese
Phasto
Portuguese
Romanian
Russian
Sign Language
Spanish
Tagalog
Telugu
Turkish
Ukrainian
Urdu
Vietnamese
Yoruba
Highest Grade Completed
Associate's Degree
Bachelor's Degree
Doctoral Degree
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Some College
Training Certificate
Vocational School
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
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
Is there another parent or guardian living in the same household? If so, please complete the following for the secondary adult.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
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.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Unspecified
White
Hispanic
Yes
No
Other Language
Akan language
American Sign Language
Arabic
Bangla/Bengali
Creole
Dari
Deutsch
English
French
Georgian
Gha
Gujarati
Hebrew
Hindi
Italian
Japanese
Khmer
Korean
Laotian
Malay
Malayalam
Mandarin
Nepalese
Phasto
Portuguese
Romanian
Russian
Sign Language
Spanish
Tagalog
Telugu
Turkish
Ukrainian
Urdu
Vietnamese
Yoruba
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
Doctoral Degree
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Some College
Training Certificate
Vocational School
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Family Information
In order to determine if your family's income is at or below the Federal Income Poverty Guidelines, we must know how many individuals are living in your household who are (1) supported by the income of the parent(s) or guardian(s) of the child enrolling in the program and (2) related to the parent(s) or guardian(s) by blood, marriage or adoption, and/or (3) the child's authorized caregiver or legally responsible party. In the section, "Number in Family" please use this definition.
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
Akan language
American Sign Language
Arabic
Bangla/Bengali
Creole
Dari
Deutsch
English
French
Georgian
Gha
Gujarati
Hebrew
Hindi
Italian
Japanese
Khmer
Korean
Laotian
Malay
Malayalam
Mandarin
Nepalese
Phasto
Portuguese
Romanian
Russian
Sign Language
Spanish
Tagalog
Telugu
Turkish
Ukrainian
Urdu
Vietnamese
Yoruba
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
Child (Applicant)
Please complete this section for the first child you wish to enroll. If you are pregnant and applying for yourself, please re-enter your information.
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Unspecified
White
Hispanic
Yes
No
Other Language
Akan language
American Sign Language
Arabic
Bangla/Bengali
Creole
Dari
Deutsch
English
French
Georgian
Gha
Gujarati
Hebrew
Hindi
Italian
Japanese
Khmer
Korean
Laotian
Malay
Malayalam
Mandarin
Nepalese
Phasto
Portuguese
Romanian
Russian
Sign Language
Spanish
Tagalog
Telugu
Turkish
Ukrainian
Urdu
Vietnamese
Yoruba
Other Language Proficiency
Little
Moderate
None
Proficient
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)
2022-2023 Early Head Start
Prenatal to 3 Years Old
2022-2023 Head Start
Ages 3-5 Years Old
1st Location Preference
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2nd 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
Please call 401-367-2001 or email at headstartenrollmentinfo@ebcap.org if you are not able to complete this on-line application. East Bay Community Action Program serves all eligible residents, regardless of their gender, age, race, or income status.
Required information is missing, see above.