You are interested in one of our Educational Programs at the Santa Clara County Office of Education and you want someone to contact you with additional information.
Parent/Guardian
Please make sure to fill out this section completely.
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
Other Language
African Languages
American Sign Language
Caribbean Languages
East Asian Languages
English
European/Slavic Languages
Middle East & South Asian Languages
Native Central American
Native North American or Alaskan
Pacific Islander Languages
Spanish
Vietnamese
Highest Grade Completed
Bachelor's or Advanced Degree
High School Graduate or GED
Less than High School Graduate
Some College, Vocational, or AA/AS
Employment Status
Employed Full Time
Employed Full Time & Training
Employed Part Time
Employed Part-time & Training
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)
Click here
to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Please complete this section if Secondary Parent is related by Blood, Marriage, Adoption or Foster.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
Other Language
African Languages
American Sign Language
Caribbean Languages
East Asian Languages
English
European/Slavic Languages
Middle East & South Asian Languages
Native Central American
Native North American or Alaskan
Pacific Islander Languages
Spanish
Vietnamese
Highest Grade Completed
Bachelor's or Advanced Degree
High School Graduate or GED
Less than High School Graduate
Some College, Vocational, or AA/AS
Employment Status
Employed Full Time
Employed Full Time & Training
Employed Part Time
Employed Part-time & Training
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
If you receive any government aid such as TANF, Cash Aid, or SSI you are eligible for our services. If you do not receive government aid please add your annual gross income before taxes.
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
African Languages
American Sign Language
Caribbean Languages
East Asian Languages
English
European/Slavic Languages
Middle East & South Asian Languages
Native Central American
Native North American or Alaskan
Pacific Islander Languages
Spanish
Vietnamese
Is another language being acquired or learned at home?
Yes
No
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
Emergency Contacts
Add Emergency Contact
Child (Applicant)
In child notes please include if your child has an active Individualized Educational Plan (IEP) or Individualized Family Service Plan (IFSP).
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
Other Language
African Languages
American Sign Language
Caribbean Languages
East Asian Languages
English
European/Slavic Languages
Middle East & South Asian Languages
Native Central American
Native North American or Alaskan
Pacific Islander Languages
Spanish
Vietnamese
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
23-24 State Preschool
23-24 Head Start
23-24 EHS Center Based
23-24 EHS Basic
23-24 EHS CCP
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
Siblings
Are there other children in the family?
Add a Sibling
Required information is missing, see above.