Apply Online

Please complete the following questions to the best of your knowledge. If you have any questions while completing this application, please call Kayla Palmer at (717)337-1337 ext 228 or email at kfpalmer@achsaccess.org. Thank you for your interest in our program! After you complete this application, please send or bring in a copy of your child's birth certificate, proof of income (w-2, income tax 1040 form, two pay stubs, proof that you receive SNAP benefits, signed note from employer, social security, and/or child support documentation) for anyone who is living with and supporting the household. Proof of income & birth certificates can be mailed (705 Old Harrisburg Road, Gettysburg, PA, 17325) or E-mailed kfpalmer@achsaccess.org**************This information is needed to process your child's application.

Please complete all of the following questions about the primary adult (the adult that is completing this application)

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

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 (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.

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status (Required)

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

Please included your mailing address if it is different than the living 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

Please complete all of the following questions about the secondary adult. If you have any questions, please call (717)337-1337 ext 228.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

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.

SSN

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?

Are there other adults in the household?

Add Another Adult

Please complete the following questions

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home?

Number in Household (Required)

Number in Family

Gross Annual Income

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?

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

Please complete the following questions about the child that you want in the Adams County Head Start Program.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Insurance 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 program! After you complete this application, please send or bring in a copy of your child's birth certificate, proof of income (w-2, income tax 1040 form, two pay stubs, two pay stubs, proof that you receive SNAP benefits, signed note from employer, social security, and/or child support documentation) for anyone who is living with and supporting the household. Proof of income & birth certificates can be mailed (705 Old Harrisburg Road, Gettysburg, PA, 17325) or E-mailed (kfpalmer@achsaccess.org)

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings