Please complete the requested information. PLEASE NOTE THAT COMPLETING THIS FORM DOES NOT MEAN YOUR CHILD IS ENROLLED IN HEAD START.
Parent/Guardian
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
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.
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
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
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 (birth to three)
Early Childhood Program for children birth to 3
Head Start (three to five) 5th DOB after 8/15
Pre-school program for children ages 3 to 5 (5th DOB after 8/15)
Early Head Start (birth to three)
Early Childhood Program for children birth to 3
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 your interest in the Head Start program. A representative from the program will be contacting you soon!
Required information is missing, see above.