Apply Online

****IF YOUR FAMILY HAS PREVIOUSLY SUBMITTED AN APPLICATION OR HAD A CHILD ENROLLED WITH HEAD START/EHS/ECEAP PLEASE STOP HERE AND CALL 360 442 2800 OR EMAIL US AT headstart.info@lowercolumbia.edu**** Please fill in the form completely and accurately. All information will be kept confidential. It will be used to help us determine if your family is eligible for services and to prioritize your placement on the waiting list. If you have any questions about this application, or need any help in completing it, please call us at 360-442-2800 or email headstart.info@lowercolumbia.edu. We will be glad to help! Once we receive your application, we will send you an email for ENROLLMENT REQUIREMENTS: Income verification and immunizations.

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (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 (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.

Race (Required)

Hispanic (Required)

Lives with Family

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Teen Parent

Homelessness includes children living: Doubled up due to economic hardship In motels, hotels, or campgrounds. In shelters. Awaiting foster care Without a fixed nighttime residence In public spaces. Without essential utilities (water, electricity, heat) or basic facilities (kitchen, toilet)

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

Lives with Family

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Are there other adults in the household?

Add Another Adult

One Parent Family- One parent living in the home with custody Two Parent Family-Two parents living in the same home with custody

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

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?

Add Emergency Contact

If you have any concerns for your child regarding vision, hearing, speech, learning difficulties, behavior, abuse/neglect or is on an IEP/IFSP, please list those concerns in the note section below. This section asks, "Is there anything else you want to tell us about your child".

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic

English Proficiency

Other Language

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

I certify that this eligibility information is true. I understand that if I knowingly give false information or misrepresentation of my income, it may result in disqualification from the program. I understand that the information in this application will be held in confidence within the agency and is accessible to me during normal business hours. Lower Columbia College Head Start/ECEAP does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. LCC is an AA/EEO employer – lowercolumbia.edu/aa-eeo.

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