GENERAL INFORMATION: 1. We must be able to reach you in order to enroll your child. **If you move or change your phone number after completing this application it is your responsibility to notify Head Start.** 2. Only a pregnant mother, parent or legal guardian may complete this application. 3. You must provide proof of your child’s date of birth with one of the following types of documents: Birth Certificate, hospital documentation, etc. (You do not need to provide a Social Security Number (SSN) in order to be eligible for Head Start.) INCOME/CATEGORICAL ELIGIBILITY: 1. If your family is a current recipient of TANF benefits and/or is receiving Supplemental Security Income (SSI), or is providing foster care for the child you are applying for, you automatically qualify for Head Start. **You do not need to provide proof of income, but you must provide documentation that your family is currently receiving TANF, SSI or providing care for a foster child. 3. If you are currently homeless, you are automatically eligible for Head Start and do not need to provide documentation of income, but must sign our Homelessness Verification Form. **Applications are considered INCOMPLETE if the above required documents & verifications for children and families are not provided to program staff.**

Parent/Guardian

Address

**Parents/Guardians may be asked to provide proof of physical addresses. **We must be able to reach you in order to enroll your child. If you move or change your phone number after completing this application, it is YOUR responsibility to notify Head Start.
Click here to find a provider in your area.

Additional Parent/Guardian

Other Adults

Are there other adults in the household?

Add Another Adult

Family Information

GENERAL INFORMATION: 1. We must be able to reach you in order to enroll your child. **If you move or change your phone number after completing this application, it is your responsibility to notify Head Start.** 2. Only a pregnant mother, parent or legal guardian may complete this application. 3. You must provide proof of your child’s date of birth with one of the following types of documents: Birth Certificate, hospital documentation, etc. (You do not need to provide a Social Security Number (SSN) in order to be eligible for Head Start.) INCOME/CATEGORICAL ELIGIBILITY: 1. If your family is a current recipient of TANF benefits and/or is receiving Supplemental Security Income (SSI), or is providing foster care for the child you are applying for, you automatically qualify for Head Start. **You do not need to provide proof of income, but you must provide documentation that your family is currently receiving TANF, SSI or providing care for a foster child. 3. If you are currently homeless, you are automatically eligible for Head Start and do not need to provide documentation of income, but must sign our Homelessness Verification Form. **Applications are considered INCOMPLETE if the above required documents & verifications for children and families are not provided to program staff.**

Child (Applicant)

Location Preferences
- 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
**CCCC Head Start 0-5 Program does not discriminate against children or families on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status.** You will be contacted, either by phone or by mail, regarding the status of your application. Thank you for you interest in the CCCC Head Start program!
Required information is missing, see above.