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Thank you for your interest in the CSRA - EOA Head Start. Please note, this is NOT a guarantee for enrollment in the program, the pre-screening application starts the process of determining your eligibility. Please, read and answer each question that is applicable to your family. Please complete this form to begin the Head Start application process. All fields marked with a * are required

Adult in the House who is the Parent/Legal Guardian. *note* This Person will be Primary Point of Contact Please answer questions about education, employment and income based on the date of the application. For teen parents, only enter "Yes" if 19 years or younger on the date of application.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

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

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

You must provide your current 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

Only complete this section if the Secondary Adult is currently living in the home, being supported by the same income, and related by blood marriage or adoption. *note* Adult is considered 18 years old or older

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.

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?

The Office of Head Start defines family as all persons living in the same household who are supported by the child’s parent(s)’ or guardian(s)’ income; and are related to the child’s parent(s) or guardian(s) by blood, marriage, or adoption; or are the child’s authorized caregiver or legally responsible party. 1st Example: Mother lives with father (blood, marriage, adoption, or legal guardian) and they both provide financial support for three children. The number in the family is five. For TANF, SSI, WIC or SNAP only answer "Yes" if you are currently receiving those benefits. Proof of income and copies of award letters will be requested.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Family

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?

WIC ID (if applicable)

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

All fields marked with a * are required. If your child has an IEP or IFSP in place, please enter the diagnosis along with the services begin and end dates, in the note section.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

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

Are there other children in the family?

Add a Sibling

You have one last step after you select save and continue. The next screen allows you to "Upload Documents". Please, scan or take a picture of the documents and upload them using your phone, computer or IPhone. Please, select save and continue.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings