Please complete all requested information in its entirety.
Parent/Guardian
First Name (Required)
Last Name (Required)
Nickname
Birthday (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
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 (Required)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic (Required)
Yes
No
Highest Grade Completed (Required)
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 (Required)
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
Custody (Required)
Yes
No
Provides Financial Support (Required)
Yes
No
Teen Parent
Yes
No
Address
Please, place the address where you and your child reside. If you are homeless please give us the address of the housing location where you are currently staying.
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Only complete the is section if the Secondary Adult is currently living in the home, being supported by the same income and related by blood, marriage or adoption.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (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
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 (Required)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic (Required)
Yes
No
Highest Grade Completed (Required)
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 (Required)
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 (Required)
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Provides Financial Support (Required)
Yes
No
Family Information
Proof of income will be requested (TANF/SNAP benefits packet OR pay stubs, W-2 if you are employed).
Number of Parents/Guardians (Required)
One Parent Family
Two Parent Family
Relationship to Participant(s) (Required)
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 (Required)
American Sign Language
English
Spanish
Spanish
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)
Yes
No
Is your family receiving Supplemental Security Income (SSI)? (Required)
Yes
No
Is your family receiving services from WIC? (Required)
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)
Yes
No
Is at least one parent/guardian an active duty member of the United States military? (Required)
Yes
No
Is at least one parent/guardian a veteran of the United States military? (Required)
Yes
No
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender (Required)
Female
Male
Race (Required)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic (Required)
Yes
No
English Proficiency (Required)
Little
Moderate
None
Proficient
Other Language
American Sign Language
English
Spanish
Spanish
Primary Health Coverage (Required)
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Does your child have a disability or do you have any concerns about your child's development? (Required)
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
Pregnant Women & Children up to age 36 months
Head Start
PreK 3 & PreK4 (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
Thank you for your interest in Bright Beginnings, Inc. Please click submit to finalize your application. We will contact you to schedule your intake appointment.
Required information is missing, see above.