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First Name (Required)

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

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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.

SSN

Race

Hispanic

English Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

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Mailing Address same as Living Address

Mailing Address

Address Line 2

City

State

ZIP

Is there another parent/guardian in the family?

First Name (Required)

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.

SSN

Race

Hispanic

English Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned 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?

WHAT YOU WILL NEED WITH YOUR HEAD START APPLICATION 1. Your tax forms, or W2 forms, or check stubs from the past 12 months, or a letter from your employer stating gross wages for the past 12 months and Proof of TANF, SSI, Child Support or any school-related grants, if you receive them. 2. Your child’s immunization record, even if it’s not complete. 3. Your child’s birth certificate. Your child’s medical, dental and immunization records can be FAXED to 406-723-5620. You will also be asked for: • Any custody papers/parenting plan regarding your child. • Name, address and phone number of child care provider. • Name, address and phone number of your emergency and release-to-contacts. • A copy of your child’s IEP (Plan for services in school) or IFSP (Plan for services with Family Outreach), if he/she receives services.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

SSN

Race

Hispanic

English Proficiency

Primary Health Coverage

Other Coverage

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

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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

Parents, In the note section under "Is there anything else you want to tell us about your child?" Please notify us about the following: I consent to pictures and videos being taken of my child at Head Start to be used in newspapers, brochures, TV and bulletin boards for public relations (Photos and identification tags are necessary for education and safety purposes). Is your son or daughter potty trained? Does your child receive speech and language services? Is your child receiving any mental health services? Transportation is not a requirement or available in all locations. If available, will you be needing bus services for your child? Living Address or Day Care. Thank you for your interest in the Action Inc. Head Start Program. By clicking the button below you certify that the information your have provided is complete and accurate. We will contact you to set up an intake appointment.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings