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Thank you for your interest in the CCRI Early Head Start – Child Care Partnership program. EHS services children ages zero through two years of age. Please note, this interest form is the first step to determine your eligibility. Even if your child is eligible for Early Head Start, service is NOT guaranteed, as there are limited funded spaces. Please attach your child care subsidy voucher if you have one before submitting the application. Families with subsidy vouchers may receive priority. If you are interested in also applying for the subsidy voucher program, please call 704-348-2181. ** This application is for first time applicants. If you have previously applied, please contact 704-376-6697.

Please complete all sections. Incomplete applications will not be considered.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

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

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Please complete all sections including apartment number, city, state and zip code.

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.

Race

Hispanic

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

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

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?

Add Emergency Contact

Please complete all sections. Incomplete applications will not be considered.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race

Hispanic

Primary Health Coverage

Insurance Number

Medicaid Number

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

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 expressing interest in the CCRI Early Head Start – Child Care Partnership program. To complete, please press the submit button below.

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