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Thank you for your interest in the Early Learning Coalition of Palm Beach County's Early Head Start Program. Our Early Head Start Childcare Partnership grant serves children between age 0 to 3 within the following communities: Riviera Beach and West Palm Beach (zip codes 33401, 33404 & 33407); Belle Glade and Pahokee. Please complete the application form to get started.

Please provide information about the primary adult.

First Name (Required)

Last Name (Required)

Suffix

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

Home Phone

Work Phone

Ext.

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

What is your current address?

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

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

Mobile Phone

Home Phone

Work Phone

Ext.

Race

Hispanic

Employment Status

Child's Relationship

Lives with Family

Provides Financial Support

Teen Parent

Give us a little bit more information about your family.

Number of Parents/Guardians

Primary Language at Home

Number in Household

Gross Annual Income

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?

Please provide information about the child (applicant).

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

Other Language

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

Dentist/Dental Home

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)

1st Location Preference

2nd 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 your interest in the Early Learning Coalition of Palm Beach County's Early Head Start Program. Please click "submit" to finalize your application. We will contact you to set up an intake appointment.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings