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Thank you for your interest in the Head Start and Early Head Start Program. Please complete the application in it's entirety, failure to complete the entire application, will delay the application/ wait list process.

Please complete the application in it's entirety, failure to complete the entire application, will delay the application/ wait list process.

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 (Required)

Home Phone (Required)

Work Phone (Required)

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

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

English Proficiency

Highest Grade Completed

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Please complete the application in it's entirety, failure to complete the entire application, will delay the application/ wait list process.

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.

Please complete the application in it's entirety, failure to complete the entire application, will delay the application/ wait list process.

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

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

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

Highest Grade Completed

Employment Status

Child's Relationship

Provides Financial Support

Are there other adults in the household?

Add Another Adult

Please complete the application in it's entirety, failure to complete the entire application, will delay the application/ wait list process.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

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?

Add Emergency Contact

Please complete the application in it's entirety, failure to complete the entire application, will delay the application/ wait list process.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

SSN

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

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

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

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

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

Thanks for reaching out and completing the Pre- application. If you are apply for Early Head Start (child is younger than 3 years old) someone will contact you or contact alwarence@porterleath.org If you are applying for Head Start (child will be 3 or 4 on or before Aug 15th) (In-person Interview is a mandatory) You have completed the 1st step of the application process but still have to complete the In-person interview and bring all the necessary documents. The next step is to attend one of our In-person Interview, schedule at this link https://www.signupgenius.com/go/10C044CA9AA2BABFFC34-61800399-head Please continue to check the website for upcoming events. www.porterleath.org/headstart

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