Dear Parent Guardian, if you are interested in an Enrollment Packet, please fill out the following information. We will have a Family Service Advocate come and assist you in filling it out. Remember, this is a general interest form, not an enrollment packet. The information you enter in this is what we will use to contact you to begin the actual enrollment packet.
Parent/Guardian
First Name (Required)
Middle Name
Last Name (Required)
Birthday (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
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
Hispanic/Latino
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
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.
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
American Sign Language
English
Lakota
Spanish
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
WIC ID (if applicable)
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Emergency Contacts
Add Emergency Contact
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Location Preferences
Which program are you applying for? (Required)
2023-2024 School Year Early Headstart
2023-2024 School Year Headstart
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd 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
Thank you for your interest in the Head Start Program. By clicking the button below, you certify that the information you have provided is complete and accurate. We will be in touch with you soon! If you have any questions, comments, or concerns, you can always contact our admin office at 605-747-2391.
Required information is missing, see above.