Welcome to the Blue Water Community Action on-line interest form. We serve children from birth thru age 4. Age eligibility is determined September 1, 2109 for the 2019-2020 program year. Please complete the form for all members of your family who are eligible. IF YOU HAVE HAD A FAMILY MEMBER ENROLLED IN HEAD START OR EARLY HEAD START WITHIN THE LAST 10 YEARS, PLEASE DO NOT USE THIS ONLINE FORM. Call 982-8541 to apply. If you are pregnant and would like to apply for Early Head Start, please call our main office at 810-982-8541.
Parent/Guardian
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
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
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Cambodian
Chinese
English
Romanian
Sign Language
Spanish
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
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
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
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
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
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Cambodian
Chinese
English
Romanian
Sign Language
Spanish
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Family Information
Please provide the following information as an estimate to determine eligibility. Proof of income will be required.
Number of Parents/Guardians
One Parent Family
Two Parent Family
Gross Annual Income
Child (Applicant)
Please complete an application for all children under the age of 3. Pregnant women and children 0 thru 2 years old are eligible for Early Head Start. (use September 1, 2018 of the program year to determine age)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
SSN
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Cambodian
Chinese
English
Romanian
Sign Language
Spanish
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Location Preferences
Which program are you applying for? (Required)
2019-2020 Early Head Start
Home based program for pregnant women and children up to 3 years old.
2019-2020 Preschool
Preschool for children ages 3 to 5
1st Location Preference
<p></p>
2nd Location Preference
<p></p>
- 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
Siblings
Are there other children in the family?
Add a Sibling
Thank you for your interest in the Head Start/Early Head Start/GSRP programs. Please hit submit when finished with your form. A Blue Water Community Action representative will be contacting you for additional information. THIS IS NOT A COMPLETE APPLICATION. Income and additional information is needed before your child can be put on the waitlist.
Required information is missing, see above.