Parent/Guardian
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Last Name (Required)
Birthday (Required)
Gender
Female
Male
Email Address (Required)
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Mobile Phone
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Home Phone
Work Phone
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Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
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
Dakota
Dinka
English
German
Hindi
Lakota
Sign
Spanish
Tagalog
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
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
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.
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
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
Dakota
Dinka
English
German
Hindi
Lakota
Sign
Spanish
Tagalog
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
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
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
Dakota
Dinka
English
German
Hindi
Lakota
Sign
Spanish
Tagalog
Number in Household
Number in Family
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
WIC ID (if applicable)
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Emergency Contacts
Add Emergency Contact
Child (Applicant)
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
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
Dakota
Dinka
English
German
Hindi
Lakota
Sign
Spanish
Tagalog
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
Doctor/Medical Home
605 Vison
A to Z Pediatrics
All Points Health-Yankton
All Women Count Program
Allina Health Northfield Clinic
AMG Family Health Center Dr. Mea
AMG Family Medical Group
AMG Family Medicine - Mitchell S
AMG Optometry
AMG Pediatrics Mitchell
Arnold, Christine, M.D.
Aurora Coumnty WIC
Aurora County Community Health
Avera (Mitchell)
Avera Chamberlain Clinic
Avera Delaney Clinic
Avera Freeman Clinic - Freeman
Avera Grassland Clinic- Kimkee
Avera Grasslands Mitchell, SD
Avera Grasslands -Mitchell-Teget
Avera Lake Andes Clinic
Avera McGreevy Pediatrics
Avera McGreevy Pediatrics
Avera McGreevy Salem
Avera McKennan Hospital
Avera Med. Grp. McGreevy-Salem
Avera Medical Clinic -Winner, SD
Avera Medical Group Family Med.
Avera Medical Group Gregory
Avera Medical Group Pierre
Avera Medical Group-Grassland Dr
Avera Medical group-Hardington
Avera Medical Group-Winner
Avera Medical Group-Yankton
Avera MG Aberdeen Family Physici
Avera MG Family Health C. S.F.
AVERA PARKSTON CLINIC
Avera Pediatrics Plus-Mitchell
Avera Platte Medical Clinic
Avera SB RHC - Tripp
Baltimore Maryland
Barnett, John, PA-C
Barondeau, Jesse, M.D.
Bartling, Melissa, M.D.
Beirreis, Jeremy, M.D.
Birch, Brian, M.D.
Bon Homme Family Practice
Bonesteel Medical Clinic
Boote, Rochelle, M.D.
Boschee, Chris, M.D.
Boswick, Sherri, M.D.
Brule County WIC
Bruning, Kara, M.D.
Bubak, Gary, M.D.
Bubak, Mark, M.D.
BURKE HEALTH CLINIC
Campbell, Theresa, M.D.
Cassandra Gutzner-PA-C
Chamberlain School
Chase, Tia, P.A.-C.
Children Home Society
Children's Physicians Dundee
Childrens HOspital &Medical Cent
Christensen, Martin, M.D.
Clark, Andrew, M.D.
CORE Education Coop
Corsica Medical Clinic
Dakota Family Medical Center
Dr. Hoekman
Dr. Jennifer Klein, MD
Envision Eye Care
Exact Eye Care
Feistret-Leuning, Heidi, M.D.
Feser, Aaron, O.D.
Ft. Thompson IHS
Gerlach, Renae, P.A.
Graham ENT - Mitchell SD
Granite Falla Health Clinic-MN
Greene, Derek, M.D.
Gregory Avera Clinic
Gregory Medical
Hafiz, Shakil, M.D.
Haines, Tia, P.A.-C.
Hartford Clinic
Henry, Scott, M.D.
Hetland, Nancy, O.D.
Horizon Health
Horizon Health -Yankton
Horizon Health-White River
Horizon Healthcare
Horizon, Plankinton
Huron Regional Medical Center
Indian Health Service
Jatczak, T.J., C.N.P.
Jerauld county com. health cente
Johnson, Jeff, M.D.
Jones, Tracy A., D.O.
Jones, Tracy, D.O.
Kafka, Richard, M.D.
Kee, Kim, C.N.P.
Kimball Medical Clinic
Krall Eye Clinic - Mitchell
Krell -Vermillion Medical Clinic
Krell, Matthew, M.D,
Lawndale Christian Health Center
Lewis & Clark Specialty
Lim, Peter, M.D.
Lions Club
List, Mark, M.D.
Lower Brule IHS Health Center
Lubbers, Vicki, C.N.P.
Luebke, Marlys, M.D.
Mabee Eye Clinic
Madison Reginal Health System
Market Place insurance
Mason, Thomas G., M.D.
Mayo Clinic
McGreevy Pediatrics
Mellette County CHC
Midwest Ear, Nose & Throat
Mission Medical Clinic
Missouri Valley Crisis Center
Mitchell Clinic, Ltd.
MRO
Nelson, Candace, M.D.
No Doctor provider
No Physical Provider
Olson, Bretta, M.D.
Olson, Lacey, M.D.
Olson, Mary J., M.D.
Olson, Michael, M.D.
Parker Medical Clinic
Peds Plus
Permann, Alexander, O.D.
Peters, Daniel, O.D.
Platte Medical Clinic
Prairie Health Clinic-Armour
Prairie Health Clinic-Corsica
Prestbo, Aaron, M.D.
Rasmussen, Paul, M.D.
Rual Medical Clinic Bridgewater
Sanford 26th & Sycamore Family M
Sanford 32nd & Ellis Sioux Falls
Sanford 34th And Kiwanis
Sanford 69th & Louise Clinic
Sanford Chamberlain Clinic
Sanford Children's Clinic
Sanford Children's Clinic
Sanford Children's MB2 Clinic
Sanford Clinic-Highland Mall
Sanford ENT (Sioux Falls
Sanford Eye Center and Optical
SANFORD FAMILY MEDICAL- SF
Sanford Hartford Clinic
Sanford Health -Sioux Falls
Sanford Health Mitchell- Dr Arno
Sanford Health Vermillion
Sanford USD Medical Center
Sanford) Viborg Clinic
Sanger, Larissa, M.D.
Sanger, Travis, M.D.
Sattler, Tressa, C.N.P.
Schoenfeld, Teri, C.H.N.
Schreur, Emily, FNP-C
Schroeder, Beth, C.N.P. P.A.
Scotland Medical Clinic Avera
SD Quitline
SD School For The Deaf
Searcy, Anastasia, D.O.
Siedle, Robert. M.D.
Singer, Reuben Md
Smith, Megan, M.D,
South Centra Educational Coop
South Central Child Development
Standford 34th And Kiwanis Fam
Tegetoff, Jennifer, M.D.
Timmer, Nathan, M.D.
Van Heukelom, Jesse, M.D.
Vetter, Wendy, D.O.
Viborg Medical Clinic
Vision Care-Yankton
Vogel, Joseph C., M.D.
Wagner Community Clinic
Wagner IHS
Wagner, Joni, PA-C
Walmart Eye Clinic
Watertown Pediatrics
Weinacht, Donna, M.D.
Wessington springs Horizon healt
WIC-Bon Homme
WIC-Charles Mix County
WIC-Gregory County
WIC-Hanson County
WIC-Hutchinson County
WIC-Jerauld County
WIC-McCook County
WIC-Mitchell
WIC-Sanborn County
WIC-Tripp County
WIC-Yankton
Willman, April, M.D.
Winner Regional Clinic
Wolter, Amber, P.A.
Woonsocket community health cent
Yankton Medical Clinic
Young, Thomas, O.D.
Zylstra, Aaron, M.D.
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dental Coverage Number
Dentist/Dental Home
ABC Pediatric Dentistry
Aberdeen Dental Associates
All Points Dental
All Smiles Dental Bus
Anderson Dental
Anderson, Susan, D.D.S.
Baltimore Maryand-Dr. Fuentes
Baumann, Jon, D.D.S.
Baune, Steven, D.D.S.
Ben Jensen Dental
Benson Dental-Sioux Falls
Beresford Neighborhood Dental
Bjerrum, Gary, D.D.S.
Black Hills Pediatric Dentistry
Bridgewater Dental Clinic
Briggs, Darcie, D.D.S.
Briggs, Michael, D.D.S.
Bunkers, Jace, D.D.S.
Carson Family Dental
Chamberlain Family Dentistry
Children's Dental Center
Chris Dickes Family Dentistry
Cortez, Paul, D.D.S.
Dailey Dental
Dailey, Matthew, D.D.S.
Dental Bus
Dental Care Center
Dental Designs
Dental Health Partners
Designer Dentistry & Smiles
Determan, Amber, D.D.S.
Dick, Mary, D.D.S.
Dickes Family Dentistry
Dickes, Chris, D.D.S.
Dickes, Chris, D.D.S.
Dr. Kusek Family Dentistry SF
Dr. Lashley
Drake Dental - Mitchell SD
Drake, Tim, D.D.S.
East Ridge Dental Sioux Falls
Farnham, Brett, D.D.S.
First Calss Dental Care
Freeman Dental
Fremont Children's Dentistry NEB
Fulton, Josh, D.D.S.
Gullings, Stephen, D.D.S.
Haberman, Holly, C.N.P.
Haiar, David, D.D.S.
Hanson, Thomas, D.D.S.
Hart Family Dentistry
Hart, Christopher, D.D.S.
Hart, Christopher, D.D.S.
Hoffman, Clayton G., D.D.S.
Horizan's Wessington Springs
Horizon Dental Plankinton
Horizon Health Care Dental Howar
Houska, Randy, D.D.S.
Hull Design
Hull, Joseph, D.D.S.
IHS Dental-Fort Thompson
IHS Dental-Wagner
Jensen, Ben D.D.S.
Johnson, Curtis, D.D.S.
Kappenman Family Dentistry
kennewick dental
Kersenbrock Dental Care
Kimball Dental
Knutson Family Dental
Knutson, Matthew, D.D.S.
Lawndale Christian Health Center
Lilly Family Dentistry
Maher Dental - Pierre SD
Manke, William, D.D.S.
Maple Park Dental Associates
Marion Dental Clinic
McCook County Dental
Miskimins, Paul, D.D.S.
Mitchell Dental Care Center
Morrison Dental Clinic
Murdo Dental
My Pediatric Dentiat
Neighborhood Dental
Neighborhood Dental
No Dental Provider
Park Center Dental Center
Parkston Dental Clinic
Pediatric Dentistry
Pierre Dental Clinic
Platte Dental Clinic
Prairie Smile Family Dentistry
Prairie Winds Dental Clinic
Reardon, William, D.D.S.
River Front Dental Clinic
Riverview Dental
Rumpca, Aaron, D.D.S.
Rushmore Ambulatory Surgery Cent
Sand hills Family Dentistry
Schoenfelder, Bryan, D.D.S.
Schuler, Jaclyn, D.D.S.
Scott Family Dental
Sioux Land Oral & Maxillofacial
Smiles 4 Kids (GDFC)
Southeastern Dental Center
Taggart, John, D.D.S.
Thielen, Damon, D.D.S.
Vermillion Dental Clinic
Wagner Family Dental
Wagner Family Dental
Weber, John, D.D.S.
Whitesell, Alex, D.D.S.
Williamson, Mark, D.D.S.
Willow Creek Dental
Winner Dental Clinic
Winner Family Dentistry
Winthers, DOrsay, D.D.S.
Yankton Community Health Dental
Yankton Dental Clinic
Yankton Family Dentistry
Yankton Horizon Dental Service
Yankton Horizon Health Care Inc.
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Location Preferences
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HS 2020 - 2021
HS 2021 - 2022
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Siblings
Are there other children in the family?
Add a Sibling
Thank you for your interest in the Head Start Program. Please click submit to finalize your application. We will contact you to set up an intake appointment. If you are an existing family in Head Start we need you to call our main office in order to enroll. 605-384-3683.
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