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We are excited that you are interested in the Head Start program. Please fill out to the best of your knowledge with the requested information.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

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 (Required)

Opt In for Text Messages

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)

Hispanic (Required)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

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)

Middle Name

Last Name (Required)

Suffix

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 (Required)

Opt In for Text Messages

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)

Hispanic (Required)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home?

Number in Household (Required)

Number in Family

Gross Annual Income

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Is at least one parent/guardian an active duty member of the United States military? (Required)

Is at least one parent/guardian a veteran of the United States military? (Required)

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home (Required)

Dental Coverage

Dental Coverage Number

Dentist/Dental Home (Required)

Does your child have a disability or do you have any concerns about your child's development? (Required)

Is there anything else you want to tell us about your child?

Food Allergy (Required)

Type of Food Allergy

Health Concern (Required)

Type of Health Concern

Disability (Required)

Type of Disability

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 the Head Start program. Please click Submit to finalize your application. Head Start staff will reach out to you within 3 business days. Family Service staff will ask for required documents to determine eligibility and you will need to fill out the enrollment forms packet. If you are interested in applying for an open job position, please visit our website- https://www.ccsct.org/careers/

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings