Apply Online

Welcome to the Online Application Portal of ESAAA/CAA Project Head Start. OUR PROGRAM SERVES FAMILIES WITH CHILDREN AGES 3-5 YEARS OLD. Please fill out ALL necessary form spaces below. If you have any questions regarding this application, please contact Mrs. Roxie Smith, Child Care Coordinator via email at rsmith@esvaheadstart.org or by calling 757-787-8774. If you are experiencing technical difficulties using this online app, please contact Mr. Will Weeks via email at sysadmin@esaaacaa.org or by calling 757-442-9652. Again, thank you in advance for giving us an opportunity to serve you!

Please fill out all information fields below to the best of your knowledge. All information requested below better enables our staff to process your application in a timely manner.

First Name (Required)

Last Name (Required)

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

Opt In for Text Messages

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

Hispanic

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

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

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

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

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

Hispanic

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

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?

Is your family receiving Supplemental Security Income (SSI)?

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?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

SSN

Race

Hispanic

Other Language

Primary Health Coverage

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

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)

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

Thank you for your interest in our Head Start Program. Please click on the "Submit" button below to finalize your application. A management team member will be in touch with you shortly.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings