Apply Online

Please fill out all blanks. Once your application is submitted, someone from our office will be contacting you.

Please fill out all of the information below. This will help expedite the application process.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

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

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.

Lives with Family

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

If you have a post office box, please provide a street address. This helps determine the bus route.

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

Please fill out all of the information below. This will help expedite the application process.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

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.

Lives with Family

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Are there other adults in the household?

Add Another Adult

Please fill out all of the information below. This will help expedite the application process.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

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?

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

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

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

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

Please fill out all of the information below. This will help expedite the application process.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

SSN

Race

Hispanic

English Proficiency

Primary Health Coverage

Medicaid Number

Dental Coverage

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

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

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 ERBA Head Start. Please click "Submit" and someone from our office will be contacting you. You will be required to provide proof of income, the child's shot record and a copy of your child's certified birth certificate. Your child's application will be considered incomplete until these documents are provided. You may fax them to 217-331-7022, email them to carrie@erbainc.org or upload documents after you "Save and Continue".

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings