Apply Online

Welcome to COTRAIC Early Head Start Online Application. You will be asked to submit documentation for income and birth records. If you have those, you can submit them at the end of this application. This application is for Children birth-3 years old only. **If your child has already attended or you've applied in person, please do not resubmit an online application. This will Delay the application process.** Please fill out as much of the application as possible. We look forward to working with your family.

First Name (Required)

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

Hispanic

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship (Required)

Custody

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.

Only list a Secondary Adult IF they are related to the child by blood, marriage, or adoption; or are the child’s authorized care giver or legally responsible party. ***If the adult does NOT MEET this criteria, SKIP this section and add that Adult as Other Adult in section below. ***

Is there another parent/guardian in the family?

First Name (Required)

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 (Required)

Opt In for Text Messages

Home Phone (Required)

Work Phone (Required)

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

Hispanic

Other Language

Highest Grade Completed

Employment Status

Child's Relationship (Required)

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians

Primary Language at Home

Is another language being acquired or learned at home?

Number in Household

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?

Add Emergency Contact

This Application is for children birth-3 years old.

First Name (Required)

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

Primary Health Coverage

Medicaid Eligibility

Doctor/Medical Home (Required)

Dentist/Dental Home (Required)

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 submitting your Early Head Start Application. Our in-take team will review your application and contact you at the phone # you provided within approximately 1 week. This phone call will help determine your child's eligibility and enrollment options. Should you have immediate questions, please call our office at 412-431-4339 and ask to speak with someone on the Intake Team.

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