Please complete this form to begin the Head Start application process. All fields marked with a * are required
Parent/Guardian
Adult in the House who is the Parent/Legal Guardian *note* This Person will be Primary Point of Contact
First Name (Required)
Last Name (Required)
Birthday (Required)
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
Home Phone
Work Phone
Ext.
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Another Adult in the House who is the Parent/Legal Guardian *note* Adult is considered 18 years old or older
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
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
Home Phone
Work Phone
Ext.
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Location Preferences
Which program are you applying for? (Required)
Early Head Start for the 2019-2020 School Year
Free Preschool for Children Ages 0 through 2. Low-Income Full Time working Parent(s) or Full Time Student(High School, GED, and Undergrad) or Community Service Requirment
Head Start for the 2019 - 2020 School Year
Free Preschool for Children Ages 3 to 5
1st Location Preference
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2nd 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
Thank you for your interest in the CSRA EOA Inc. Head Start Program. Upon receipt of this inquiry form, you will be contacted about the documents necessary to determine eligibility.
Required information is missing, see above.