Apply Online

Thank you for applying with SAL Community Services Early Head Start! We look forward to serving you. If you need any assistance with completing the online application, or if you have any questions, please feel free to contact Katy at (309) 850-0184, or e-mail Katy at cbell@salcommunityservices.org

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (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.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency (Required)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

Opt-in for Email (Required)

How you heard about us? (Required)

Other: (Required)

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

Please complete if the other parent or stepparent of any of your children is residing in the home with you.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (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.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency (Required)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home?

Number in Household

Number in Family (Required)

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?

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

Please complete this section for the child that you're wishing to enroll in the Early Head Start program. If you wish to enroll multiple children in the Early Head Start program, please complete a separate online application for each child you're enrolling.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency (Required)

Primary Health Coverage (Required)

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?

Parent/Guardian Signature

Date of Event (Required)

Name of Community Event (Required)

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

Thank you for submitting your Early Head Start application! We will be contacting you very soon to schedule a time to complete the Early Head Start application process. Please note that, by submitting this online application, you are certifying that the information you've provided is complete & accurate. If any false information is shared, your participation in SAL Community Services' Early Head Start program may be terminated & you may be subject to legal action. Also note that the information shared on this application is held in strict confidence within SAL Community Services and is accessible to you during normal business hours.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings