Apply Online

Thank you for your interest in CASEWV Head Start and Early Head Start, including PreK services in Mercer and Summers counties. Please complete this application in its entirety. If you need assistance or if your child or family has previously been enrolled in any of our program options or filled out an application, call (304)425-9539. Are you an expectant mother? Visit this web page to apply: https://www.casewv.org/hsquick

Please fill out all parts of this application completely.

First Name (Required)

Middle Name

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

Lives with Family

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Teen Parent

Please put the current 911 address for your physical address and current mailing address even if it is the same as the physical 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 fill out the below information about any additional parent/guardian to the child.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

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

Lives with Family

English Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Please fill out the information below completely. Please note: The number in family is the immediate family while number in home is the amount of people living in the house.

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 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?

Add Emergency Contact

First Name (Required)

Middle Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

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

Thank you for completing this application. Once we have reviewed your application, we will contact you. The next page is a survey of your experience with the application process to this point, designed to help us improve our application process.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant