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Thank you choosing our Program! Applicant's must be 3 or 4 years old on or before August 1 to qualify for our program. When completing this application, please keep in mind to provide the information for whom the enrolling child is living with. Head Start requires for the application to consist of one household. For example: If Parents are divorced, only one Parent should fill out the application with the information of the people living in that particular household. You can add the additional parent under "Additional Parent" heading, be sure to mark correctly if they live with the family. It is important that your application be complete. Please do not leave any fields blank.

The Primary Adult is the child's biological parent or legal guardian. If you are a legal guardian then you must submit court documents for proof of custody.

First Name (Required)

Middle Name

Last Name (Required)

Nickname

Birthday (Required)

Gender (Required)

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.

SSN

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Lives with Family (Required)

Provides Financial Support (Required)

Teen Parent

Place of Employment (Required)

If your mailing address is different than your living address please supply both.

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

The secondary adult is another adult in the home to whom the primary adult is legally married to or is the biological parent of the ENROLLING child.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Nickname

Birthday (Required)

Gender (Required)

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.

SSN

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Lives with Family (Required)

Provides Financial Support (Required)

Teen Parent

Place of Employment (Required)

Are there other adults in the household?

Add Another Adult

Please remember, this information is in regards to the Primary and Secondary Adults in the household.

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

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? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

WIC ID (if applicable)

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

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

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

Add Emergency Contact

Applicant's must be between the ages of 3-5 years old before August 1 to qualify for our program.

First Name (Required)

Middle Name (Required)

Last Name (Required)

Nickname

Birthday (Required)

Gender (Required)

SSN

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Medicaid Eligibility (Required)

Medicaid Number

Dental Coverage

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

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

Child's Physician (Required)

Child's Dentist (Required)

Consent for Home visits (Required)

Consent for Screens (Required)

Picture Consent (Required)

Guidance Counselor (Required)

Informal Observations (Required)

School Records (Required)

Emergency Services (Required)

Dental Exam (Required)

BMI Screen Letter (Required)

Blood Pressure (Required)

Consent Valid (Required)

Consent Signature & Date: (Required)

Routine Dental Care (Required)

Routine Vision Exam (Required)

Glasses (Required)

ENT/ Ear Tubes (Required)

Past Medical Conditions (Required)

Present Medical Condition (Required)

Child's Medical Condition (Required)

Condition Medication (Required)

Allergies (Required)

Explain Allergies: (Required)

Dietary/Nutritional (Required)

Dietary/Nutrition Concern (Required)

Information Language (Required)

Other Language

Application Signature (Required)

Signature and Date: (Required)

Privacy Signature (Required)

Signature: (Required)

How did you hear about us (Required)

Flyer/QR Code- Location

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

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings