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The following is a Pre-Application for Kosciusko County Head Start/ Early Head Start. Completing this Pre-Application does not mean that your child is automatically enrolled in the Head Start or Early Head Start Program.

Please answer the following questions about education and employment based on the date of the application.

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (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 (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 (Required)

Hispanic (Required)

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Lives with Family (Required)

Provides Financial Support

Teen Parent

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

Only complete this section if the Secondary Adult is currently living in the home and related by blood, marriage, or adoption.

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (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 (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 (Required)

Hispanic (Required)

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Lives with Family

Provides Financial Support

Teen Parent

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home? (Required)

Number in Household (Required)

Number in Family (Required)

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Is at least one parent/guardian an active duty member of the United States military? (Required)

Is at least one parent/guardian a veteran of the United States military? (Required)

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

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? (Required)

Is there anything else you want to tell us about your child?

How did you hear about us (Required)

Currently in EHS

Rent, Own, Live w/Family

Someone expecting baby?

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

I understand that this is only the application for Kosciusko County Head Start/EHS and this document does not guarantee enrollment in the program. I also understand that I must keep Head Start/EHS informed of any changes of address and phone number. For Head Start: I understand I will need to provide transportation to and from the Head Start classroom if my child is enrolled into the program. I certify that the information stated on the application is true and I have provided Head Start/EHS with all the facts necessary to allow the determination of eligibility. If any part is false, my participation in this program may be terminated. I also understand that the information in this application will be kept confidential within the program.

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