Apply Online

PLEASE NOTE: online applications are for NEW families only. If you have another child that has been in the program before or have already applied in the past, please submit a hard copy application. DUPLICATE APPLICATIONS WILL SLOW DOWN THE PROCESS. You can download a fillable .pdf version at www.capbm.org under Services>Early Care & Education>View Early Care & Education Resources and email to headstart@capbm.org Thank you!

Thank you for your interest in our Head Start or Early Head Start programs. Please fill out the application completely to the best of your ability. We cannot process your application without proof of income and child age verification. You may upload that here now or at a later date. You will be emailed a link you can use to return to this at any time to upload documents.

Please make sure to answer ALL questions

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

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 (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

Please fill out your current physical address and mailing address if it is different than your physical address.

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

The second adult living in the home that is supported by the parents/guardians income and is related by blood, marriage, or adoption.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

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 (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency

Other Language

Other Language Proficiency

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

Gross income is income BEFORE deductions. If you receive SNAP, SSI, or TANF benefits you may put 0. *Note: Household size and family size will not always be the same. Office of Head Start definitions: Family: "Family means all persons living in the same household who are supported by the child’s parent(s)’ or guardian(s)’ income; and are related to the child’s parent(s) or guardian(s) by blood, marriage, or adoption; or are the child’s authorized care giver or legally responsible party." Household will be the total number of people living in the home whether they are supported by the parent(s) financially or not. *Please note that eligibility is based only on family size per the definition listed above.

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home? (Required)

Number in Household (Required)

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? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

WIC ID (if applicable)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Is at least one parent/guardian an active duty member of the United States military? (Required)

Is at least one parent/guardian a veteran of the United States military? (Required)

Add Emergency Contact

This section is for the Child you wish to enroll. Please make sure to answer ALL questions.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

Dentist/Dental Home

Does your child have a disability or do you have any concerns about your child's development? (Required)

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

Thank you for your interest in our program. By clicking "submit" you are certifying that all information provided is true and accurate to the best of your knowledge. You will be contacted shortly to do an intake interview and complete the application process.

Please note we do NOT provide transportation. Families are responsible for getting children to the center

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