Thank you for your interest in our program! Please complete the following information and someone from our enrollment office will contact you within 3 working days to complete the application process.
Parent/Guardian
First Name (Required)
Last Name (Required)
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
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
English Proficiency
Little
Moderate
None
Proficient
Other Language
Acholi
American Sign Language
Arabic
Bangoli
Cantonese
Chinese
English
French
KinyaRwanda
Kirundi
Lingala
Portuguese
Sign Language
Somali
Spanish
Swahili
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
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 or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
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
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
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.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
English Proficiency
Little
Moderate
None
Proficient
Other Language
Acholi
American Sign Language
Arabic
Bangoli
Cantonese
Chinese
English
French
KinyaRwanda
Kirundi
Lingala
Portuguese
Sign Language
Somali
Spanish
Swahili
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
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 or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Family Information
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
Acholi
American Sign Language
Arabic
Bangoli
Cantonese
Chinese
English
French
KinyaRwanda
Kirundi
Lingala
Portuguese
Sign Language
Somali
Spanish
Swahili
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?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
SSN
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
English Proficiency
Little
Moderate
None
Proficient
Other Language
Acholi
American Sign Language
Arabic
Bangoli
Cantonese
Chinese
English
French
KinyaRwanda
Kirundi
Lingala
Portuguese
Sign Language
Somali
Spanish
Swahili
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
Medicaid Number
Doctor/Medical Home
Aardvark Pediatrics
Advance Clinical Eye Care
Allergy And Asthma Assoc.
Androscoggin Home Health
Auburn Medical Assoc.
B-Street Family Health Center
Be Well My Friend
Beeaker, William OD
Benjamin Liess, MD, FACS
Berman, Jeff OD
Biddeford Pediatrics
Casco Bay Eye Care
CCS Family Health Center
CCS Pediatrics
CCS- Optical Dispensary
Central Maine Audiology
Central Maine ENT
Central Maine Pediatrics
Central Me Family Practice
Central ME Family Residency Prog
Central ME Orthopaedics
CMMC Gray Family Health CTR
CMMC Med. Info. Records
CMMC OBGYN
CMMC Vaccine person
Dartmouth Hitchcock Med. Ctr.
DeRosa, Chamberlain and Cote
DFD Russel Medical Center
Family Eye Health Center
Family Health Care Asscoc.
Franklin Health Family Practice
Franklin Health Med. Records
Franklin Health Pediatrics
Gorman, Alison
Hallowell Family Practice
Hamilton, Wade
Hanger Clinic
Happy Kids Pediatrics
Harry E. Davis Pediatric Center
Health Partners
Healthy Androscoggin
Hearing Healthcare Assoc
InterMed Pediatrics
Intermed Pediatrics Yarmouth
Jean Antonucci, MD
Jean Antonucci, MD
Katie Beckett- MaineCare
Kennebec Pediatrics
Knapp, Michelle
L/A Hearing
Lakes Region Primary Care
Lavin, C. William -Maine General
Lincoln Medical Partners Primary
Lisbon Family Practice
Livermore Falls Family Practice
Maine Dartmouth Family Practice
Maine General Medical Center
Maine Med medical information
Maine Optometry
MaineCare
MaineGeneral Allergy & Asthma
Martin's Point Healthcare
Martin's Point Pediatrics
Mercy Health Information
MidCoast Medical ENT
Midcoast Pediatrics
Minot Avenue Family Practice
MMP Otolaryngology
MMP Ped. Spec. Pulmonology
MMP Portland Family Medicine
MMP Portland Pediatrics
MMP-Falmouth Pediatrics
Northern Sun Family Health
Norton, Troy - Norton Eyecare
Optometric Assoc.
Pediatric Associates
Penner, Gregory - ENT
Penobscot Community Health Care
Pine Tree Legal
Poland Community Health Ctr
Poland Family Practice, St. Mary
Portland community Health Center
Promise Early Education Center
Public Health Nurse
Riverside Eye Center
Sawyer, Randolph
South Portland Pediatrics
SSI- Social Security Income
St. Mary's Family Practice
St. Mary's Med. Information
St. Mary's Orthopaedic
St. Mary's Women's Pavillion
Swift River Health Center
Topsham Family Practice
Trinity Jubilee Center
Tufts Floating Children's Hospit
W.I.C.
Walmart Optical Shop
Western ME Family Practice
Western ME Health Information
Western ME Healthcare
Western ME Pediatrics
Wintrop Pediatrics & Adolecent
Wright, Dr- Bridgton Primar Care
Yarmouth Primary Care
York Family Practice
Dentist/Dental Home
Androscoggin Dental Group
Aspen Dental Auburn
Aspen Dental Topsham
Augusta Pediatric Dentistry
Bangor Childrens Dentistry
Brilliant Smiles Dental Hygiene
CCS Dental Center
Center for Advanced Dentistry
Children&Family Dentistry& Brace
Coastal ME Ped. Dentistry
Community Dental- Farmington
Community Dental- Lewiston
Community Dental-Portland
Complete Dentistry
Connelly, Kevin DMD
Dirigo Pediatric Dentistry
Drews Dental Service
Evergreen Dental
Falmouth Pediatric Dentisty
Family and Cosmetic Dentistry
Farmington Dental
Gentle Dental
Great Falls Dental
Independent Practice Dental Hygi
Jesse Albert Center
Joy Dentistry
Just For Kids
Kay, Roger DMD
Kennebec Valley Dental Center
Lisbon Family Dental
Main Street Dental
Maine Oral Maxillofacial Surgery
Maple Way Dental Care
Mount Auburn Dental
Riverview Dental
Ross, Bruce
Strong Area Dental Center
Taylor Brook Dental
Wee Care Children's Dentistry
Willow Run Dentistry
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)
Head Start
Serving children that are 3 or 4 yrs of age by 10/15/2020
Early Head Start
Serving expectant mothers and children birth through 4 years of age
1st Location Preference
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2nd 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 for your interest in our Program. Please make sure to click on the submit button to finish your application.
Required information is missing, see above.