Apply Online

Thank you for your interest in the HWC Adventure Head Start Program. Please complete the entire application and click submit at the bottom. On the "Location Preferences" section, you must first choose Head Start (ages 3-4) or Early Head Start (pregnant women and children ages 0-2). By submitting this application, you agree to your contact information being shared with your Local Education Agency (Public School) in an effort to coordinate any screening services for your child regardless of acceptance into the program. If you have submitted an application in the past for any child in the family, please call (918)967-0748 or email Shelly Rethman at srethman@healthwellnessok.com.

Please provide us with this information for the Primary Adult.

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.

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

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

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

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

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody

Provides Financial Support

Teen Parent

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home (Required)

Is another language being acquired or learned at home?

Number in Household (Required)

Number in Family (Required)

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?

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home (Required)

Dental Coverage (Required)

Dental Coverage Number

Dentist/Dental Home (Required)

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

Recruitment (Required)

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 HWC Adventure Head Start Program. You will be contacted to complete the application and eligibility process. By submitting this application, you are certifying that the information provided is true. If any part is false, your participation in this program may be terminated. Please click "Submit" to finalize your application.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings