Head Start is a center-based preschool program for children 3-5+ years of age. Early Head Start is currently a home-based program for children 0-3 and pregnant mothers. EHS services to children will be center-based next school year. Please complete the following information and Head Start Birth to 5 staff will contact you to complete the intake process. Head Start Birth-5 must have the following items to complete the intake process: ___Head Start Birth-5 Application (one per applicant) • All sections must be completed. ___Eligibility Documentation for relevant family members (one of the following) • If the child is in Foster Care, please provide a written statement from DCS. • If the family receives SNAP, SSI, or TANF please provide documentation. • If the family does not receive any of the above, please provide income documentation such as: W2, 1040, check stubs, child support payments, and/or unemployment. ___Interview with Head Start Staff (in person) ___Birth Certificate • Indiana Daycare Licensing requires a Birth Certificate for all children. • Expectant mothers do not have to provide a Birth Certificate. ___Documentation of Diagnosed Disability • If your child has an IEP or IFSP please provide a copy.
Parent/Guardian
First Name (Required)
Last Name (Required)
Suffix
Birthday (Required)
Gender (Required)
Female
Male
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
Yes
No
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)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Unspecified
White
Hispanic (Required)
Yes
No
Lives with Family (Required)
Yes
No
Highest Grade Completed (Required)
Advanced Degree or Bachelor's Degree
Associate Degree, Vocational School, or some college
High School Graduate or GED
Less than High School Graduate
Employment Status (Required)
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 (Required)
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody (Required)
Yes
No
Provides Financial Support (Required)
Yes
No
Teen Parent (Required)
Yes
No
Housing (Required)
Homeless
Other
Other Permanent Housing
Own
Rent
Dwelling type (Required)
Mobile home
Other/Homeless
Site built multi-unit
Site built single
Disabled (Required)
Yes
No
Military status
Active
Veteran
Medical Insurance (Required)
Direct-Purchase
Employment Based
Medicaid
Medicare
Military Health Care
None
State Children's Health Insurance
State Insurance for Adults
Unemployment type
Long-Term (more than 6 mo.)
Not in Labor Force
Retired
Short-Term (6 mo. or less)
Employment
No income
TANF
SSI
Soc. Sec. Disability Ins.
VA service disability
VA service pension
Private disability ins.
Worker's compensation
Soc. Sec. retirement
Pension
Child support
Alimony
Unemployment ins.
EITC
Other
SNAP
WIC
LIHEAP
Housing choice voucher
Public housing
Perm. supportive housing
HUD-VASH
Chilcare voucher
Afforable CARE Act sub.
Other benefit
Monthly income (Required)
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 (Required)
Female
Male
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
Yes
No
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)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Unspecified
White
Hispanic (Required)
Yes
No
Lives with Family (Required)
Yes
No
Highest Grade Completed (Required)
Advanced Degree or Bachelor's Degree
Associate Degree, Vocational School, or some college
High School Graduate or GED
Less than High School Graduate
Employment Status (Required)
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 (Required)
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody (Required)
Yes
No
Provides Financial Support (Required)
Yes
No
Teen Parent (Required)
Yes
No
Disabled (Required)
Yes
No
Military status
Active
Veteran
Medical Insurance (Required)
Direct-Purchase
Employment Based
Medicaid
Medicare
Military Health Care
None
State Children's Health Insurance
State Insurance for Adults
Unemployment type
Long-Term (more than 6 mo.)
Not in Labor Force
Retired
Short-Term (6 mo. or less)
Employment
No income
TANF
SSI
Soc. Sec. Disability Ins.
VA service disability
VA service pension
Private disability ins.
Worker's compensation
Soc. Sec. retirement
Pension
Child support
Alimony
Unemployment ins.
EITC
Other
SNAP
WIC
LIHEAP
Housing choice voucher
Public housing
Perm. supportive housing
HUD-VASH
Chilcare voucher
Afforable CARE Act sub.
Other benefit
Monthly income (Required)
Family Information
Number of Parents/Guardians (Required)
One Parent Family
Two Parent Family
Relationship to Participant(s) (Required)
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 (Required)
African Languages
American Sign Language
Caribbean Languages
East Asian Languages
English
European and Slavic Languages
Middle Eastern and South Asian Languages
Native Central American, South American, and Mexican Languages
Native North American/Alaska Native Languages
Pacific Island Languages
Spanish
Is another language being acquired or learned at home? (Required)
Yes
No
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)
Yes
No
Is your family receiving Supplemental Security Income (SSI)? (Required)
Yes
No
Is your family receiving services from WIC? (Required)
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)
Yes
No
Is at least one parent/guardian an active duty member of the United States military? (Required)
Yes
No
Is at least one parent/guardian a veteran of the United States military? (Required)
Yes
No
Child (Applicant)
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender (Required)
Female
Male
Race (Required)
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Unspecified
White
Hispanic (Required)
Yes
No
Related to LHDC Employee (Required)
Yes
No
Employee name:
Disabled (Required)
Yes
No
Medical Insurance (Required)
Direct-Purchase
Employment Based
Medicaid
Medicare
Military Health Care
None
State Children's Health Insurance
State Insurance for Adults
No income
SSI
Other
Monthly income
Location Preferences
Which program are you applying for? (Required)
Early Head Start
Pregnant Women and Children 0-3 years old
Head Start
Children 3-5 years old
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. Staff will contact you to complete the intake process. If you have any questions please call 1-800-467-1435 ext. 302.
Required information is missing, see above.