The following is an interest form for SCCAP Head Start Preschool and Early Head Start.
Parent/Guardian
Please answer questions about education, employment, and income based on the date of the application.
First Name (Required)
Middle Name
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 (Required)
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Chinese
English
French
Indonesian
Kinyarwanda
Mandarin
Other (Please Specify in Note Section)
Russian
Spanish
Swahili
Ukrainian
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
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
Family Information
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
American Sign Language
Arabic
Chinese
English
French
Indonesian
Kinyarwanda
Mandarin
Other (Please Specify in Note Section)
Russian
Spanish
Swahili
Ukrainian
Vietnamese
Number in Family
Gross Annual Income
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Child (Applicant)
Please use this section to fill out information about your child.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
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)
Early Head Start
Free Early Learning Program for Children Ages 6 weeks to 3 years old
Head Start for 2024-2025 School Year
Free Preschool for Children Ages 3 to 5
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
You will receive an email confirmation once the application is submitted. We will contact you within 5 business days to schedule an appointment to complete the registration process. You are responsible for updating contact information if it changes. We will only use the numbers and addresses submitted to notify you of your child's status.
Required information is missing, see above.