Early Head Start is a free, year-round program for qualifying families. We are now accepting referrals for our Bedford location from community partners and families who wish to self-refer. Operating hours are Monday through Friday, 9:00 am - 3:00 pm; transportation is not provided. If you or your client have a child under the age of 33 months and would like to begin the eligibility process for our Bedford Center, please complete the following pre-application. PLEASE NOTE: EHS is unable to process applications for children over 33 months (2 years, 9 months).
Parent/Guardian
First Name (Required)
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
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Cebuano
English
English as Second Language
French
Macedonian
Other
Spanish
Tagalog
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Teen Parent
Yes
No
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.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
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
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Cebuano
English
English as Second Language
French
Macedonian
Other
Spanish
Tagalog
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Teen Parent
Yes
No
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
Cebuano
English
English as Second Language
French
Macedonian
Other
Spanish
Tagalog
Is another language being acquired or learned at home?
Yes
No
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?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
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
Child (Applicant)
First Name (Required)
Last Name (Required)
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
Doctor/Medical Home
Access HealthCare Multi-Spec.
Amherst Co. Health Dept.
Asthma and Allergy Center
Audiology Hearing Aid Assoc.
Bedford Co. Health Dept.
Blue Ridge ENT & Plastics
Blue Ridge Medical Center
Blue Ridge Therapy Associates
Carilion Children's Ped. Med
Carilion Clinic - Bedford
Carilion Clinic- Daleville
Centra Autism and Dev. Center
Centra Medical Group - Amherst
Centra Medical Group - Bedford
Centra Medical Group - Village
Community Access Network
Cornell Scott-Hill Health Center
CVFP - New London
CVFP - Stanton River
F Read Hopkins Pediatric Assoc.
Free Clinic of Central Virginia
Infant & Toddler Connection
JHC-Amherst Community Health
JHC-Bedford Community Health
JHC-Lynchburg Women's & Pediat.
JHC-Rustburg Community Health
LewisGale Physicians Pediatrics
Liberty Mountain Medical Group
Lynchburg Family Medicine Res,
Lynchburg Health Dept.
Lynchburg Pediatrics
Ped. Assoc. of Charlottesville
Physicians to Children, Inc.
Prince Edward Pediatrics
Thomas E. Dobyns, MD
UVA Children's Hospital
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dentist/Dental Home
Bedford Community Dental Center
Blue Ridge Medical Center
Carilion Clinic Dental Care -Ped
Children's Dental Health Of Lync
Children's Dentistry & Orthodon.
Children's Dentistry of Charlott
Community Access Network
Free Clinic of Central Virginia
James River Dental Center
JHC-Lynchburg Women's & Pediat.
Kids First Dental - Martinsville
Kids First Dental - Roanoke
Spencer Dental
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Current Program Term
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
Siblings
Are there other children in the family?
Add a Sibling
Thank you for your interest in Early Head Start! Please click "save and continue", and a confirmation email will be sent to you when your application is received. Because this is a revolving Referral Process, there may not be current openings at the time of your pre-application. However, Early Head Start will work closely with you throughout the process to ensure you are either placed on the waitlist or provided resources for other childcare services.
Required information is missing, see above.