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Parent/Guardian
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.
English Proficiency
Little
Moderate
None
Proficient
Other Language
African-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Lingala
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Nuer
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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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)
Last Name (Required)
Birthday (Required)
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.
English Proficiency
Little
Moderate
None
Proficient
Other Language
African-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Lingala
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Nuer
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Family Information
~Child's shot record~ ~Child's birth certificate~ ~proof of family income (ie: W-2, income tax return, letter from employer)~ These documents are needed and can be emailed to: meyer@caasiouxland.org
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-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Lingala
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Nuer
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Child (Applicant)
First Name (Required)
Middle Name
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
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Lingala
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Nuer
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Other Language Proficiency
Little
Moderate
None
Proficient
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Early Head Start-Classroom based
Program for children ages 0-3 will be in a classroom setting hours 8:30-3:30
Head Start Preschool
Free full day Preschool for Children Ages 3 to 5
Early Head Start Home Visitation Program
Free program where families will recieve home visits from a home visitor weekly. During the visit they are available to answer your questions, provide parent-child educational activities and resources during visits.
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
Required information is missing, see above.