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Head Start Pre-School Program (Ages 3-5) Please complete the form below to begin your application process for the Head Start Program located in Moline, East Moline, Kewanee and Aledo. Please be sure to provide current and accurate information regarding your child and family, this is very important for the application process goes as quickly as possible. Completing this form is the first step in the application process. Our ERSEA Manager will be in contact with you after your interest form is submitted.

First Name (Required)

Middle Name

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

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)

Middle Name

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

Is another language being acquired or learned at home?

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)

Nickname

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Doctor/Medical Home

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

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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 your interest in the Head Start Program. We will contact you within 7 business days to schedule an appointment to finalize your application for the program. Please bring the following documents with you: Child's Birth Certificate, Medical Insurance Card, Income (Tax Return or W2 Forms, or SSI benefits, child support, unemployment, foster care payments, pension, disability, etc.), Physical Exam and Immunization Record including TB, Lead and Hemoglobin, 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