Thank you for your interest in applying for Early Head Start or Head Start services. Please complete all questions asked in the application. A Family Support Worker will be contacting you to set up an appointment to complete the application process. We look forward to reviewing your child's application and working with your family.
Parent/Guardian
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
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
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
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
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
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
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Family Information
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
English
Ho Chunk
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
WIC ID (if applicable)
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)
Last Name (Required)
Nickname
Birthday (Required)
Gender
Female
Male
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
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
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Doctor/Medical Home
1901 Cornhusker Dr. Suite 205
Alcohol Program
Boys Town Hospital
CCMH Medical Clinic
Children's Hospital - Omaha
Community Action Agency of Sioux
Curtis, Carl T. MD
Dakota County Health Dept
Dakota Dunes Clinic
Dental-Twelve Clans Unity
Dunes Medical Laboratories
ENT Dunes Clinic
ESU 1 Wakefield
Family Health Care
FHC Dakota Dunes Clinic
FHC Indian Hills Clinic
FHC-SSC
In Focus Eyecare, LLC
Kincaid, Fett, And Tharp
Nebraska Foundation Children's V
Northeast Eye Care
Northern Plains
Omaha Audiology
Omaha Nation WIC
Oneida Community Health Center
Optometry-Twelve Clans Unity
Pediatric Partners
Pender Community Clinic
PHN
Prairie Pediactrics
Prairie Pediatrics-Morningside
Rabbitt Family Vision Center
Siouxland Community Healh
Siouxland District Health Dept
Siouxland Medical Ed. Found.
Smile Academy Omaha Ne
South Central Child Development
Sue McLaughlin
Twelve Clans Unity Hospital
Unity Point Health
Vernae Luhr
Walker, Elizabeth MD
Walmart Vision Center
WIC Office
Winnebago Behavioral Center
Winnebago CHR
Winnebago Head Start
Winnebago Health Department
Winnebago Public School District
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Enrolled in Tribe
Yes
No
Tribal Enrollment Number
Other Tribe Name
Clan
Indian Name
Have Childcare Subsidy
Yes
No
Applied for Subsidy
Yes
No
Child Care Situation
Location Preferences
Which program are you applying for? (Required)
Head Start 2023-2024
Early Head Start 2023-2024
Head Start 2024-2025
Educare of Winnebago early childhood program
Early Head Start and Head Start for children birth to age 5
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
Siblings
Are there other children in the family?
Add a Sibling
Required information is missing, see above.