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INTAKE FORM

Please complete this intake form to begin the Head Start and/or Early Head Start application process in cities/areas served by Volunteers of America LA County. Our service areas are listed below. Even if you live outside our service area, but reside or work nearby to one of our sites we may still be able to help you.

Head Start (3 to 5 year olds)

North Hollywood, Tujunga, Shadow Hills, Studio City, Sun Valley, Valley Village
East Los Angeles, Commerce
Carson, El Segundo, Harbor City, Hawthorne, Lomita, San Pedro, Torrance, Wilmington, Rancho Palos Verdes
Culver City, Del Rey, Mar Vista, Palms
A small portion of Historic South Central Los Angeles (NW: Jefferson & Maple; NE: Jefferson & Avalon; SE: Avalon & Vernon; SW: Vernon & Main)

Early Head Start / Pre-Natal (children under 3, and pregnant women)

North Hollywood (91601, 91602, 91605, 91606); Shadow Hills (91040); Studio City (91607); Sun Valley (91352); Sunland (91040); Tujunga (91042); Valley Village (91607)
Carson (90745); Harbor City (90710); Hawthorne (90250); Lennox (90304); Lomita (90717); Rancho Palos Verdes (90275); San Pedro (90731, 90732)

Once you submit your completed intake form, a Head Start enrollment team member will contact you within 5 business days to continue the enrollment process.

The information provided will not be shown/transmitted to any other person/agency without the consent of the parents/guardians of the child.

First Name (Required)

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

Employment Status

Child's Relationship

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

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

Employment Status

Child's Relationship

Are there other adults in the household?

Add Another Adult

Gross Annual Income - Family's annual income before taxes and other deductions

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language 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 under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Primary Health Coverage

Dental Coverage

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

Thank you for your interest in Volunteers of America's Head Start program. Please click Submit Application to finalize your intake. We will contact you to set up an appointment.
Note that completing this intake does not guarantee enrollment.

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Required information is missing, see above.

INTAKE FORM

Head Start (3 to 5 year olds)

Early Head Start / Pre-Natal (children under 3, and pregnant women)

Once you submit your completed intake form, a Head Start enrollment team member will contact you within 5 business days to continue the enrollment process.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings