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Thank you for your interest in Head Start. Please prepare this information for review at your intake interview. It is needed to process & determine Head Start eligibility. 1. Proof of Income for Last 12 Months & most recent tax year. (W2 forms, 1040 tax form, pay stubs of both parents, signed employer statement, unemployment statement, TANF award letter, SSI award letter, SNAP info, Child Support statement.) 2. Proof of Child’s Age (Birth Certificate/Baptism Certificate/etc.). A child must be a minimum of 3 years old by the schools districts cut off date on Dec 1st with 4 year olds having enrollment priority. 3. Immunization Records (Shot Records) 4. Medical and Dental Insurance Card 5. Proof of Residence (Rent/Mortgage Statement, or Lease/Mortgage Agreement & Utility Bill (most recent) 6. Parent Picture Identification 7. Referral of Services (If Needed) Head Start requires every child to complete an Annual physical and dental exam. If you have previously registered a child with us, please send an email to enroll@hseoc.org with your name & date of birth, current applicants name & DOB, updated email address and telephone #. Our intake specialist will respond with additional info. Thank you.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

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

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

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

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

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

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Number in Household

Number in Family

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?

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

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health 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?

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

REMINDER-Please prepare this information for review at your intake interview. It is needed to process & determine Head Start eligibility. 1. Proof of Income for Last 12 Months & most recent tax year. (W2 forms, 1040 tax form, pay stubs of both parents, signed employer statement, unemployment statement, TANF award letter, SSI award letter, SNAP info, Child Support statement.) 2. Proof of Child’s Age (Birth Certificate/Baptism Certificate/etc.). A child must be a minimum of 3 years old by the schools districts cut off date on Dec 1st with 4 year olds having enrollment priority. 3. Immunization Records (Shot Records) 4. Medical and Dental Insurance Card 5. Proof of Residence (Rent/Mortgage Statement, or Lease/Mortgage Agreement & Utility Bill (most recent) 6. Parent Picture Identification 7. Referral of Services (If Needed) Head Start requires every child to complete an Annual physical and dental exam.

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