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The following is an INTEREST form for Long Island Head Start. The Head Start Program is for Pre-School children ages 3 to 5 - Please complete if your child will be 3 years old before December 1st. The Early Head Start Program is for children birth to 3 and an Expectant Mother Program is also available. The Early Head Start - Child Care Partnership Program is for children 6 weeks to 3 years old. After completing, a Family Advocate, Family Educator or Family Service Worker will contact you depending on the appropriate program you applied for. In order to fully process your application we would need you to kindly provide: Child's Birth Certificate, Child's Health Insurance Card, Parent Photo ID, Child's Immunization Record, and Proof of Family Income (2-3 recent pay stubs; 1040; W2; or Employer Letters - for both parents if 2 parent family).

Please fill out information about the child's parent or legal guardian.

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

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.

Please complete if you have a second parent or guardian living in the household.

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

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Number in Family

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?

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?

Please fill out information about your child. Please enter name exactly as shown on the birth certificate.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Medicaid Eligibility

Doctor/Medical Home

Dental Coverage

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?

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

Looking for employment? Long Island Head Start is currently hiring all positions. Find the employment application on our website at www.liheadstart.org. Thank you for your interest in Long Island Head Start! We look forward to meeting with you!

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings