Please be sure to fill out ALL fields for qualifying purposes.
Parent/Guardian
Please answer questions about education and income based on the date of the application. For teen parents, only enter "Yes" if 19 years or younger on the date of the application.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
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
Yes
No
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
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Languages
American Sign Language
Arabic
Caribbean Languages
East Asian Languages
English
European-Slavic-Bosnian-Russian
French
German
Italian
Pacific Island Languages
Porteguese
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Physician's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Only complete this section if the Secondary Adult is currently living in the home, being supported by the same income and related blood marriage or adoption.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
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
Yes
No
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.
SSN
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Languages
American Sign Language
Arabic
Caribbean Languages
East Asian Languages
English
European-Slavic-Bosnian-Russian
French
German
Italian
Pacific Island Languages
Porteguese
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Physician's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Family Information
For TANF, SSI, WIC or SNAP only answer "Yes" if you are currently receiving benefits. Proof of Income and copies of awards letters will be requested.
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
African Languages
American Sign Language
Arabic
Caribbean Languages
East Asian Languages
English
European-Slavic-Bosnian-Russian
French
German
Italian
Pacific Island Languages
Porteguese
Spanish
Is another language being acquired or learned at home?
Yes
No
Number in Household
Number in Family
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
WIC ID (if applicable)
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Child (Applicant)
If your child has an IEP or IFSP in place, please place the diagnosis along with services begin and end dates in the notes section below.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
Insurance Number
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
Doctor/Medical Home
ABC Children's Health Care Cente
ABC Pediatrics
Academic Primary Care Associates
Access to Care Roanoke
AFC Urgent Care
Alba, Gregory D.O.
Alleghany Public Schools
Allergy & Asthma Associates, Inc
Alpine Pediatrics
Alyse Elkins
Ann Campbell
Annapolis Pediatrics
Atrium Health
Augusta Eye Associates
Augusta Health Care for Women
Augusta Medical Group
Augusta OB-GYN
Augusta Pediatrics
Augusta Regional Free&Dental Cli
Bath Community Physicians Group
Bedford Family Care
Beverly Caldwell
Blacksburg Pediatrics
Blue Ridge Pediatrics
Blue Ridge Women's Center
Blueridge Behavioral Health
Bon Secours Health System, Inc
Boshra, Soheir MD
Botetourt County Public Schools
Boyd, William E. Jr.
Bradley Free Clinic
Brass Mill Dental
Buena Vista City Public Schools
Buena Vista Medical Associates
Cancer Support Group
Carilion Clinic Sleep Clinic
Carilion Clinic-Psychiatry
Carilion Clinic/Clifton Forge
Carilion Dental Clinic
Carilion Family Practice
Carilion Healthcare Corp
Carilion Hospice NRV
Carilion Maternal Fetal Medicine
Carilion OB/GYN
Carilion Otolaryngology/Audiolog
Carilion Pediatric - Daleville
Carilion Pediatric - Electric Rd
Carilion Pediatrics - Fallon Par
Carilion Pediatrics - Postal Dr
Carilion Riverside Circle
Carilion Roanoke Community Hosp
Carol D Miller, FNP
Carteret Clinic for Children
Centra CMG Village
Central VA Health Services, Inc
CFM - Blacksburg
CFM - Brambleton
CFM - Buchanan
CFM - Christiansburg
CFM - Colonial Ave SW
CFM - Daleville
CFM - Giles County
CFM - Lexington
CFM - Lexington, South Main
CFM - Martinsville
CFM - North Roanoke
CFM - Oakgrove
CFM - Parkway Physicians
CFM - Radford
CFM - Roanoke-Salem
CFM - Rocky Mount
CFM - Salem
CFM - Southeast
CFM - Vinton
CFM-Lexington
Charles Armory MD
Children's Choice of the NRV
Children's Clinic
Children's Health Improve. Part.
Children's Hospital
Children's Medical Center
Children's Medical Center, Ltd.
China-Uganda Friendship
CHIP
Community Access Network
Compassionate Care Pediatrics
Compress & Shock Foundation
Coozic, Dr.
Cornerstone Community Care
Covington County Public Schools
Covington Health Department
Craig County Health Center
Craig County Public Schools
CRCH Pediatric Therapy
Cummings, David (DO)
Daleville Family Med
Dodson Pest Control
Dominion Day Treatment
Dr Nur
Dr. Al-Attar, Princeton WV
Dr. Cheryl Pocht
Dr. Childs
Dr. Cramer
Dr. Harding
Dr. Harny, Wayne
Dr. Jamila Williams
Dr. John Moore
Dr. Kennedy
Dr. Keswani
Dr. Krishnan Kumar
Dr. Lafave
Dr. Landuer
Dr. Marsh
Dr. Munif
Dr. Peter Devines
Dr. Prakash Adawadker
Dr. Robert Fuller-UVA
Dr. Swatzyna
Dr. Young
Drop In Center
Early Intervention - Alleghany
Early Intervention - NRV
Early Intervention - Roanoke Val
Early Intervention - Rockbridge
Eastern Shore Children'S Clinic
Express Family Care
Express Urgent Care
Eye One / Retina Care of VA
Fairfield Medical Associates
Fincastle Family Practice
Forest Family Care
Franklin County Public Schools
Free Clinic of Pulaski County
General Booth Pediatrics
Glasgow Family Practice Inc
Gospel Way Food Pantry
Greenbrier OB/GYN
Greenbrier Physicians
HCA Health Services of VA, Inc
HD - Alleghany County/Covington
HD - Augusta County/Staunton
HD - Bath County
HD - Botetourt County
HD - Buena Vista
HD - Clifton Forge
HD - Craig County
HD - Franklin County
HD - Harrisonburg/Rockingham Co
HD - Henry/Martinsville
HD - Highland County
HD - Lexington/Rockbridge
HD - Lynchburg City
HD - Patrick County
HD - Pulaski
HD - Roanoke City
HD - Salem/Roanoke County
HD - Vinton/Roanoke County
HD - Waynesboro/Augusta County
Head Start Disibility
Heals, Inc
Health 2 Health
Health Center , Union WVA
Health Centers Of The Piedmont
Health Public
Highland Pediatrics
Inas-Atlar
Jackson River Family Practice
Jackson River Pediatrics
Jana Peters
Jana White
Johnson Health Center
Johnsons Health Center
Kaiser Permanente
Katie Williams
Kletxing, Tracy
Kool Smiles - Christiansburg
Kool Smiles - Roanoke
Lee-Hi Clinic
Lewis Gale - Pembrooke
Lewis Gale - Valley View
Lewis Gale Family Medicine
Lewis Gale Mental Health
Lewis Gale Pediatrics
Lewis Gale Physicians
Lewis Gale Pulaski Hospital
Lewis Gale-Daleville
Lewis-Gale: Blacksburg
Lewis-Gale: Bonsack
Lewis-Gale: Low Moor
Lexington City Schools
LG Cave Spring Family Practice
Liberty Mountain Medical
Lynchburg Pediatrics
Maria Ona
Maternal Fetal Meds
Maury River Family Practice
McClory, Dr.
Med-Ride
Melissa Martinez, NP
Mental Health America of RV
Meridian Crossroads
Mertes, Christopher P. (MD)
Middlebrook Family Medicine
Monroe Health
Moorestown Ped
Nansemond Pediatrics
Nationwide Children's Hospital
Navant Midcard Health
New Beginnings Pediatrics B'burg
New Garden Medical Associates
New Horizons Healthcare
New Horizons Healthcare (Melrose
New River Medical Group
New River Pediatrics
New River Valley Pediatrics
Newman, Blackstock & Associates
NHHC-
NHHC-Dr. Maria Soriano
North Roanoke Family Physicians
Northern Peds
NRV Family Health Clinic
OB-GYN Brambleton Associates
OB-GYN Carilion - Jefferson
OB-GYN Carilion - Rocky Mount
OB-GYN Riverside
Park, Chan M. (MD)
Paths Community Medical Ctr
Patient Care Plus
PECK, Thomas
Pediactric & Adolescent Medical
Pediatric Associates
Pediatric Associates Coral Sprin
Pediatric Consultants
Pediatric Place of Tampa
Pediatric Specialists
Peoples Places
Peter Grosso
Physicians to Children, Inc.
Physicians to Women
Physiology Consultants
piedmont pediatrics
PINEDA, MICHOLE, M.D.
PINKSTON, Dr.
Planned Parenthood
Premier Pediatrics
Project Horizon
Pulaski Health & Rehab Center
Pulaski Medical, LLC Methadone
Raphine Medical Associates
RARA
Ridout, Steven B. (MD)
Riggs Community Health Center
Roanoke Adolescent Health Ptnr
Roanoke City Health Dept.
Roanoke City Schools
Roanoke County Public Schools
Roanoke Family Medicine
Roanoke Medical Center for Women
Roanoke Pediatrics
Roanoke Salem Family Medicine
Roanoke Valley Speech & Hearing
Robert C. Clinic
Rockbridge Area Free Clinic
Rockbridge County Public Schools
Rockbridge Health
Rockbridge Internists Inc
Rockbridge Pediatrics
Rural Healthcare Services
Ryan, John (MD)
Sailer, Jane
Salem City Schools
Samantha Toron
SCH - REACH Program
SCIALABA, MARK A., MD
Shenandoath Community Health
Smith Mtn Lake Family Practice
Solstas Lab Partners
South Roanoke OB-GYN, PC
Southern Family Med Center
SPEAKER, DR.
Starkey Medical
Stonewall Pediatrics
Strong, Dr.
Subuhi, Dr.
Sunlight Medical
Sunshine Pediatrics
SWVA Blacksburg Peds
Tallahassee Memorial Family
TAP Head Start
Teen Health Center - PH Clinic
The Audiology & Speech Language
The Better Hearing Center Inc.
The Children's Clinic of Frederi
The Salvation Army
THOMPSON, CHAD
Tidewater Children's Assoc
Tomei, Jan MD
Town Center Pediatrics
Tri-Area Ferrum Community Health
Trumbell Pediatrics
Twin County Physicians
Utah Dept. of Health
UVA Augusta Pediatric Clinic
UVA Children's Hospital
UVA Family Medicine
UVA Pediatrics
VA Premier Health Plan
VA School For The Deaf And Blind
Valley Children Clinic, P.C.
Valley Family Practice
Valley Pediatric Group
VAMENTA, RENA DR
Van Dorn Pediatrics
Veteran's Medical Center
Village Family Physicians, Inc.
Vistar Eye Center
Volinsky, John B (MD)
Walker, Dr
Watob Pediatric
West Virginia Dept of Health
Western Virginia Ob-Gyn Ctr
Wexlen
Whole Family Center
WIC - Women Infants & Children
Wolfe, Karen E. MD
WOO, DR. EDWARD, MD
Wortley, George
Wythe Physician Practices
Wythe-Bland Pediatric Clinic
Yen Hoong Ooi
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
Dental Coverage Number
Dentist/Dental Home
Adams, Katie (DDS)
Allara, Jack M. DDS
Aloud Denistry
Alpine Family Dental
Amacher, Darcy (DDS)
Anderson & Sheppard, Inc.
Armour, William (DDS)
Aspen Dental
Augusta Regional Free&Dental Cli
Biery & Paulette (DDS)
Black, David (DDS)
Blake & Howard LLC
Bland Family Dentistry
Blue Ridge Dental
Bradley Free Clinic
Brass Mill Dental
Breame Family Dental Care
Bright Smile Dental Clinic LLC
Brumbaugh, Brian (DDS)
Buena Vista Family Dentistry
Buena Vista Medical Associates
Burke W. Soffe
Campbell, Peggy (DDS)
Carilion Clinic Dental Care
Carilion Clinic/Clifton Forge
Carilion Dental Clinic
Central VA Family Dentistry
Charlottesville Children Dental
Children's Denistry of Char.
Children's Dental
Children's Dentistry
Children's First
Children's Health Improve. Part.
CHIP
Comm Health Center of NRV
Commonwealth Dental Clinic
Community Health
Cook Family Dentistry
Coots Ward & Cross Family Dentis
Craig County Dental Center
Craig County Health Center
Cross, Lavender, Quinn & Park
Davis Pediatric Dentistry
Dental Associates
Dereus, Michael DDS
Diamond, Matin (DDS)
Dr. Alan White
Dr. Ankrum
Dr. Brown
Dr. David Jones
Dr. David Jones
Dr. Dryden
Dr. Joe Rebellato
Dr. Lavender
Dr. Mark Turner
Dr. Merritt Sparger
Dr. Peggy Lovecchio
Dr. William Moore
Dr. William O. Roller Jr
Dr.John Carter- DDS
Drs. Downey & Devening, PC
Gardener, Joel (DDS)
General Dentistry Ltd
Gilbert, James III (DDS)
Greenbrier Valley Pediatric Dent
Greene, Joseph M. DDS
Hamlin Family Dentistry
Happy Smiles
Harvey, Gregory DMD
Haun, Robert W. (DDS)
HD - Alleghany County/Covington
HD - Augusta County/Staunton
HD - Bath County
HD - Botetourt County
HD - Buena Vista
HD - Clifton Forge
HD - Craig County
HD - Franklin County
HD - Harrisonburg/Rockingham Co
HD - Henry/Martinsville
HD - Highland County
HD - Lexington/Rockbridge
HD - Lynchburg City
HD - Patrick County
HD - Pulaski
HD - Roanoke City
HD - Salem/Roanoke County
HD - Vinton/Roanoke County
HD - Waynesboro/Augusta County
Henritze Dental Group
Henritze, Andrew (DDS)
Holliday, Roger A (DDS)
Huff, Wallace L (DDS)
Hughes, Gregory (DDS)
Hull Dental Clinic
Hunting Hills Family Denistry
Intercept Health
Jackson River Pediatrics
Joachim, Richard J (DDS)
Johnson Health Center
Jones, David Lee (DDS)
Jones, Treacy (DDS)
Kevorkian, George Jr (DDS)
Kids First Dental
Kinney & Huffman (DDS)
Kool Smiles - Christiansburg
Kool Smiles - Roanoke
Lasris, Samuel R (DDS)
Lexington Smiles
Love Family Dentistry
Lowdon, J. Ian Jr.
Lynch, Dickey, Singleton
Massanutten Dental
Matthew C. Roller D.D.S.
Metz, James (DDS)
Miller, Scott (DDS)
Mills & Shannon Dentistry
moore
Morris, Clay S. DR
Mountain View Dental Team
Mountain View Dentistry
New Horizons Healthcare
New Horizons Healthcare (Melrose
Nicole Dudding, RDH
Norbo Randy J (DDS)
North Roanoke Dental Asso
NRV Pediatric Dentistry
Nunley, Daniel W. (DDS)
Paget, Jr., Joe A. (DDS)
Park Dental Solutions
Parkway Pediatric Denistry
Paths Community Medical Ctr
Paul Miller
Pediatric Dental
Pediatric Dental Care of VA - Ma
Pediatric Dental Care of VA - Ro
Physicians to Children, Inc.
Potomac Pediatric Dentistry
Real Life Dental
Reinhardt, M.
Rice Dentistry of Roanoke
Roanoke City Health Dept.
Roanoke Pediatric Dentistry
Robertson, J.K. (DDS)
Robin Oliver
Rockbridge Area Free Clinic
Ross, R. Douglas (DDS)
Sharpley, Ronald S. (DDS)
Sherman, Dr.
Sherman, Frank
Skinner, Gregory (DDS)
Slaughter And Slaughter Family
Small Smiles
Smile Starters
Smile Virginia
Smith Dental Studio
Smith Mountain Lake Dental
Southeastern Mobile Dental Clini
Souther Family Med Center
Sowers, Steven E. (DDS)
Spencer Dental Group
Spencer Dental-Richmond
Sprinkle, Grant III
Star City Family Dentistry
Steven Clark DDS
Stone, James (DDS)
Straight Smiles
STUBBS, PAUL DD.
Sunset Dental
Surat, Dr.
Tammy Wooten, RDH
Triad Dental
TURKEWWTZ
United Concordia
UVA Pediatrics
VA Premier Health Plan
Valley Family Dentistry
VAUGHAN, GARY
Vess, Fremont (DDS)
Veterans Medical Center
Virginia Western Comm. Col.
WeCare Dental
Wheeler, David L. (DDS)
William A Deyerle DDS Ltd
Willis Family Dentist
Woods, Michael L.
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Preschool for 2024-2025
Children Ages 3-5 years old
Infants/Toddlers/Pregnant Moms for 2024-2025
Expectant Mothers and Children 0 - 35 months old
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- 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
Thank you so much for your interest in our Head Start program. Someone will be in touch with you after reviewing your application.
Required information is missing, see above.