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Your application is not complete until you have filled out both sections. The general family information and the Selection Criteria. Not finishing the Selection Criteria MAY LEAD TO A DELAY IN PROCESSING your application. Program Requirements: Must provide proof of residency of Stafford County, proof of income, original birth certificate, immunization records, school physical and dental examination.

Completing an application for the program does not guarantee acceptance. Please be sure to answer all questions before submitting, as missing information will delay processing your child's application. An Interview is required as part of the application process.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

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

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.

Race

Hispanic

English Proficiency (Required)

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

PROOF OF ADDRESS
The following documents will be accepted as proof of residency for Stafford County.
*A lease or a mortgage statement (Primary)
*A current utility bill, water, electric or gas (secondary)
*Photo ID with current address
*Medical bill

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.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Suffix

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.

Race

Hispanic

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

VERIFICATION OF INCOME
Provide all applicable documents
• SNAP – Copy of your most recent statement.
• TANF - A copy of your monthly statement
• SSI - A copy of your most recent letter for SSI showing your monthly benefits.
• 1040 Tax Form for each parent in the household.
• W-2 for each parent in the household.
• Seasonal Workers - provide a statement from their employer.
• Income means gross cash income and includes earned income, military income (including pay and allowances), veterans’ benefits, unemployment compensation and Child Support
Email to headstart@staffordschools.net
The above information is true to the best of my knowledge. If any part is false, my participation in this agency’s program may be terminated.

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?

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical 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?

How did you hear about us (Required)

Food Allergies/Exceptions (Required)

Other Allergies (Required)

List Allergies

Working with ChildFind?

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

PLEASE FILL OUT EVERY QUESTION FULLY; BLANKS MAY LEAD TO A DELAY IN PROCESSING. PROOF OF INCOME IS REQUIRED BEFORE THE APPLICATION CAN BE PROCESSED. Please take a picture with your phone of the first two pages of your 1040 (most recent Tax Return) and email to headstart@staffordschools.net Fill out the Selection Criteria page at https://forms.gle/84xmbdHEbVuehxrH8 For more information or for help filling out this application, call the Head Start Office at (540) 368-2559, or Fax (540) 368-1978. The Stafford County School Board does not unlawfully discriminate against any person on the basis of: race, sex, age, color, religion, national origin, political affiliation or disability. Inquiries regarding non-discrimination should be directed to the Executive Director of Human Resources, Stafford County Public Schools, 31 Stafford Ave., Stafford, Virginia 22554, Phone (540)658-6560, FAX: (540)658-5950. Head Start does serve children with disabilities, with income eligible children taking priority. Reasonable accommodations upon request. Completing an application for the program does NOT guarantee enrollment.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings