Welcome to Community Action of South MS online application portal!

New Household Applicants Only! If you currently or in the past have had a child enrolled in the program you will need to come to our Central Office to have your child’s application processed!

This is the first step in the process to qualify your child for Head Start or Early Head Start.

Income and age verification will determine your child's eligibility for acceptance and enrollment. We also serve pregnant moms!

Please complete all fields of this form and our staff will get back to you shortly with more information. Once the application has been initiated it must be completed and submitted! The application will not save!

Parent/Guardian

Primary Adult

Primary Adult is the individual related to the child applicant by blood or marriage; it may also be the legal guardian or social worker who presents legal documents verifying their status.

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

Address

Permanent Living Address/ Mailing Address (Optional)

Living address is where the family resides (must be within the boundaries of Jackson County). Mailing address is where the family wants their mail to be sent.

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

Additional Parent/Guardian

Secondary Adult

Secondary Adult is the other adult family member related to the child applicant by blood or marriage and provides support to the family.

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

Other Adults

Are there other adults in the household?
Add Another Adult

Family Information

Family

Family is defined as "all persons living in the same household who are supported by the child's parent(s)' or guardian(s)' by blood, marriage, or adoption; or the child's authorized care giver or legally responsible individual.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

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?

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

WIC ID (if applicable)

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?

Child (Applicant)

Participant
Child (Applicant) is the infant, toddler or child (excluding an unborn child) for whom this application is being processed.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

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?

Location Preferences

Which program are you applying for? (Required)

CASOMS HEAD START

AGES 2-5 YEARS

CASOMS HEAD START

AGES 2-5 YEARS

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.

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

Once your application has been submitted, you will receive an email confirmation along with instructions and what to expect.

Required information is missing, see above.