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
Parent/Guardian
Please fill out all parts of this application completely.
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Non-binary
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
Lives with Family
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Egyptian
English
Spanish
Spanish
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Address
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?
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 fill out the below information about any additional parent/guardian to the child.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Non-binary
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
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
Lives with Family
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Family Information
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
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
American Sign Language
Arabic
Egyptian
English
Spanish
Spanish
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
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Emergency Contacts
Add Emergency Contact
Child (Applicant)
First Name (Required)
Middle Name (Required)
Last Name (Required)
Birthday (Required)
Gender (Required)
Female
Male
Non-binary
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
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Egyptian
English
Spanish
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
Doctor/Medical Home
Access Health Associates-OBGN
Access Health Pediatrics
Access Health(Jamie Blankenship)
Al-Atar, Inas
Ann Lamberndis CAMC
Appalachian Eye Care
ARH Summers Rural Health PC
Asbury Donald
Asthma & Allergy Center
Avera Medical Group
Ballard, Kim, Dr.
Bassam Nicholas Shamma MD
Beckley Pediatric & Associates
Birth to Three
Blue Ridge Hearing
Bluefield Family Medicine
Bluestone (Kegley)
Bluestone (Oakvale Rd)
Bluestone Health
Bluestone Health Center
Bluestone Medical Center
Bluewell Family Medicine
Brian S. Dunlap, MD
CAMC Cardiology-Pediatric
CAMC Ophthalmology
CAMC Pediatric ENT-Dr. Shaffer
CAMC Plateau Medical Group
CAMC Radhika Ghosh
CAMC Sana Farooki Hematology
CAMC The Family Clinc
CARLLION CHILDREND CLINIC
CASE WV Diaper Bank
Chabbra, Dr. Amarinder
Charity Hicks
Child Development Center
Coventry Health Care
Crook, Sue
Danielle Thampson
Day, Stanley
DHHR-Mercer County
Donna Southers
Dr . Albert L. Aymer
Dr .Carolyn B. Morrison
Dr .Dana Ghishan
Dr Anjum Rana
Dr Azara Singh MD
Dr David P Skoner
Dr Dina Criniti
Dr John Bishara
Dr Obidi
Dr. Ahmand A. Khiami, MD
Dr. Amanda H. Bailey
Dr. Amy Keene OD
Dr. Amy L. Brown
Dr. Ann Collins
Dr. Brandon Lingenfelter
Dr. Brian Peppers
Dr. Bruce Lasker MD
Dr. Carlos E. Lucero
Dr. Carol M. Asbury
Dr. Carolyn B. Morrison
Dr. David B. Gomez
Dr. David Clarke
Dr. Deborah Sams
Dr. Edwards
Dr. Elizabeth Johnson, PA
Dr. Florencio P. Neri
Dr. Frank Britton
Dr. Gary Veronneau OD
Dr. Ghazala Q. Khokar, MD
Dr. Gildbridge
Dr. Gomez
Dr. Haleh C Heydarian
Dr. Jana M. Peters
Dr. Jana White
Dr. Jason M Frazer
Dr. Jennifer Bailey
Dr. Joe Ellington
Dr. John Davis
Dr. John Lubicky
Dr. Jonathan Yates
Dr. K. Iqbal
Dr. Katherine M. Morrison, MD
Dr. Kathleen J. Martin
Dr. Kevin Maupin
Dr. Khokar
Dr. Kim Bennett
Dr. Kimberly D. Ballard
Dr. Lohuis
Dr. Lyndsey Weatherly
Dr. Marilyn Glaser
Dr. Mark A. Weitzel
Dr. McClintic
Dr. Michael Vacco
Dr. Michelle Morrison
Dr. Michelle Staton
Dr. Mohammad K. Iqbal
Dr. Mohammed J. Rana
Dr. Munif
Dr. Muzaffer Rahmet
Dr. Nancy A. Lohuis
Dr. NAtasha Barker
Dr. Noah Shaikh
Dr. Pamela Stallo
Dr. Patrick Ryan
Dr. Petrarca, DO
Dr. Philip Branson
Dr. Philip Light, MD
Dr. Phillip A. Peterson
Dr. Rahmet Muzaffer
Dr. Rana
Dr. Randy Brodnik
Dr. Raoul Y. Malonzo
Dr. Razia Ahmad MD
Dr. Rhodes Pediatirc Cardiology
Dr. Robert Edwards
Dr. Robert Petrarca
Dr. Robert Wade
Dr. Sabrina M. Berger
Dr. Samantha Chaffins-OB-GYN
Dr. Shahid Khokar
Dr. Shannon Bashlor
Dr. Stacy D. Dickenson
Dr. Stephen Miller
Dr. Stephen Ward
Dr. Tara Mitchell
Dr. Tarakji Muhib S. MD
Dr. Ted W. Solari
Dr. Telitha D. Glasscock
Dr. Waheed A. Khan, MD
Dr. Werblin
Dr. William Byrd
Dr. William S. Dukart
Dr. Yasier M. Kanawati, MD
Dr.Crystal Mitchell
Durnan, Nancy
Edens, Pamela
Ellington, Joe, Dr.
Faith Family Health
Family Care Clinic
Family Resource Center/REACHH
Fayette County Schools
Ferell Eye Clinic
Fernald, John Dr.
Green Valley Family Clinic
Greenbrier Audiology and Hearing
Greenbrier family medical clinic
Greenbrier Physicians Clinic
Hampton Roads Pediatrics
Harnett County HD
Head Start
Health Care Alliance PC
Help Me Grow West Virginia
Hinton Eye Care
Huffman, Jeanette, Dr
Hussain, Dr. Farid M
Jamie Carosi PA
Jana Peters
Jill D. Cochran, RNC
Joel Clinic
John Davis MD
Johnson John H MD
Karen McBride, Mental Health
Kay Westfall Speical Needs
Kid Care Pediatrics
Kids Care Clinic
Ladonna Renae (Wolfe) Bowling
Laurel Ridge Psychological Asso.
Lincoln Pediatrics Clinic
Lindsey Optical
Lively Pediatrics Tara Mitchell
Lynnetta Payne Advanced Urology
Medical Device Depot
Melrose Family Medicine
Mercer Asthma-Allegry-Immnlgy
Mercer County Board of Education
Mercer County Health Department
Mercer Medical group
Mercer Medical Group ENT
Misty Dillow
Monroe Health Center
Morgantown Specialist
Mountain View Pediatrics
New Hope Family Practice
Novant Health Forsyth Pediatrics
Pamela Faulkner
Pediatric Associates Va.
Pediatric Dentistry Of Beckley
Prime Care 12 Priority Health
Princeton Community Hospital
Prudich Medical Center
Rahmet Muzaffer
Rainbow Pediatrics
Rainelle Medical Center, Inc
Ranielle Medical Center
Rebecca Nicholson-Lilly
Rheumatology Pediatric
Richmond Pediatric
Right From the Start
Roanoke Memorial Hospital
Robert C. Byrd Clinic
Robert Wade, East River Eye Care
Robin Ridele
Rose, Dr.
Runyon, Ryan, Dr.
Sadat Taoufik A MD
Samantha Nunley Bluestone Health
Sandy Cottle
Shannon Bashlor, FNP
Shorter, Dr.
Shriners Children's Lexington
South Central Educational Dev
SOUTHERN HIGHLAND CMHC
Stepp, Joni Dr.
Summers ARH Clinic
Summers County Board of Educatio
Summers County Health Department
Summersville Pediatrics, INC
Taravath Sadidharan MD
Taylor, Donald
Tazewell Community Health
Tazewell County Health Dept. WIC
The Blaydes Clinic
The Eye Center Of Greenbrier Va
Timothy Reed
Tina Webb
Tug River Health Clinic
Waitkus, Charles Dr
Walker Rozelle J MD+
WIC
WIC
Winchester Pediatric Clinic
WVU Medicine Children's
Wythe Eye Associates
Yung Hie Koh, MD
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dentist/Dental Home
Andrada & Rose DDS
Ben Lamb DDS
Bland County Medical Clinic
Bluefield Dental Assocites
Bluefield Dental Care
Bluestone Dental Clinic
Branson Family Dentistry
Bridget Stevens
Charles E. Lane Jr DDS
Children's Dentistry
Cline Family Dentistry
Conklin, Thomas, DDS
Darcy Amacher
DDS Micheal Meadows
Dice, Gerald, DDS
Doersch, Mary Kay
Dr Rieber
Dr Tom Honaker
Dr. Charles Lane DDS
Dr. Christy Kenna Fox
Dr. David McCormack
Dr. David Najar,DDS
Dr. Gene R Carr
Dr. Hubert Byron Jr. DMD
Dr. James K. Martin, DDS
Dr. Jody Ann Meredith
Dr. Jon Lovern
Dr. Jon Lovern M DDS
Dr. Kevin Lucky
Dr. Kevin Lucky DDS
Dr. Lewis D. Gilbert, DDS
Dr. MA Farid DMD DDS
Dr. Martin & Kirk
Dr. Miller James
Dr. Paul A Gilley
Dr. R. Alan May
Dr. Steven D. Lutz
Dr. Steven Lutz
Dr. Veneri
Dr. William Klenk
Dr.Tom Honaker, DDS, PLLC
Erica W. Reed- DDS
Ethan Lafferty DDS
Family Dental of Virgina-Hampton
Gilley, Paul, DDS
Glen L. Catron D.M.D
Godwin, James, DDS
Goforth, Harold DDS
Greenbrier Valley Pediatric
Hale Family Dentistry
Harvey Dental Studio
Hoke Family Dentistry
Jeff Jarrell DDS
Jeffrey Harvey R DDS
Jill Shumate
Joseph Vaughan, DDS
Kids First Dental
Kilcollin Dental-Union
Lawson Family Dentistry
Liberty Dental
Linkous, Harold, DDS
Martin Dental Associates
Michael Bagby
Najar, David, DDS
New River Health-Dental
Oceana Dental Center
Opulent Pediatric Dentistry
Osborne, James, DDS
Pediatric Dentistry Of Beckley
Pediatric Dentistry of Beckley
Pillion and Smith
Robert Stevens DDS
Rodebaugh Family Dentistry
Ronald Householder
Rose, Dr.
Schwarz, Jack, DDS
Spencer Dental
teays valley dental care
Teays Valley Pediatric Dentistry
Thomas Conklin
Tim Nichols DDS
TLC Dental Care
TLC Dentist
Triad Kid Dental
Williams DDS
Williams Family Dentistry
Young Smiles
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)
Early Head Start 2024-2025
Head Start 2024-2025
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
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.