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Thank you for your interest in Head Start preschool ages 3-5 and Early Head Start home base prenatal and birth to 3 for the 2023-2024 Program year! Please enter information on ALL persons living in your home and include income information for the Primary and Secondary Adults to help us determine eligibility. The 2024-2025 application will be available April 1. Your child must be age eligible for Head Start at time of application. If a member of your family has been in our programs previously, please contact Stefanie Valdez at 740-205-8040.

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)

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.

SSN

Race

Hispanic

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

If your address includes a P.O. Box, apartment number/letter, or lot number please include that in this section.

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.

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Are there other adults in the household?

Add Another Adult

Please enter all members of your household. Family size helps determine eligibility.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Household

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?

Our Early Head Start program serves prenatal Moms as well as children birth to 3. If you are applying as a prenatal Mom, please let us know in the applicant notes and answer the applicant questions with your own information instead of child. Does your child have an IFSP or IEP? Please answer "Yes" to "Does your child have a disability" and provide any information you think would be good for us to know in the notes.

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

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? (Required)

Is there anything else you want to tell us about your child?

Recruitment (Required)

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 application to our program. An email will be sent to the ERSEA Specialist notifying her that your application is available for review. You will be contacted if additional information is needed and receive notification by mail when your child has been added to the waitlist.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings