Apply Online

Welcome to our Early Head Start Application Process. We serve Expectant Mothers and infants and toddlers ranging from six weeks to three years of age. Since the success of your child is our priority, One Place staff is striving to provide this time for you to begin the application process independently using our online platform. Please allow yourself 30 minutes to complete the application in its entirety, as you will not have an opportunity to return to an application or save any responses. You will have an opportunity to upload all supporting documents into our secure database at the end of this portion of the application. A list of required supporting documents can be found at: https://www.oneplaceonslow.org/for-parents-and-early-educators/infant-toddler-programs/

Primary adult is the child's parent or guardian by blood, marriage, or adoption and lives in the home with the child. Please name the adult that is the legal guardian and who is financially responsible for the child.

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 (Required)

Opt In for Text Messages

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 (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent (Required)

Please type the address where you and your child live.

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 (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

The secondary adult is the child's parent or guardian by blood, marriage, or adoption; authorized care-giver or legally responsible party. Only list the secondary adult if they live in the home with the child.

Is there another parent/guardian in the family?

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 (Required)

Opt In for Text Messages

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 (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent (Required)

Are there other adults in the household?

Add Another Adult

Family means all persons living in the same household who are supported by you, the parent, guardian, or care-giver. An emergency contact is a local family member, friend, or neighbor we may contact in case of emergency or if we are unable to contact you at the phone number or email provided on your application.

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned 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? (Required)

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

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? (Required)

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

Provide information for the child for which you are submitting an application for.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Medicaid Eligibility

Doctor/Medical Home (Required)

Dental Coverage

Dentist/Dental Home (Required)

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 completing the first steps in applying for our Early Head Start program. Your information has been received in our online database and a team member will be in contact with you to schedule your application intake and Family Interview. If you have not received a response after 14 days of applying, please feel free to contact Cassie Minerva, ERSEA Specialist, at 910-333-0612.

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