Apply Online

This application is used to start the application process for the Head Start program (birth-5 years old and pregnant women services). If you have applied within the past 5 years for our program, please contact the center instead of completing this online application. *Starting the application process online does not guarantee acceptance into the program.

Primary adult must live in the home and have custody of the child to complete application.

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (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 (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 and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

Please list your current address. If your address changes after submitting please contact the center to update in the system.

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

Secondary adult must live in the home, be supported by the adult, and related to the primary adult by blood, marriage, or adoption.

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

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 and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

Please complete this section about family information.

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home?

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)

Please complete this section for all children or pregnant women who are applying for services. If your child has a disability, diagnosed health conditions, allergies, mental health diagnosis, etc...please provide additional information in the notes.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender (Required)

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Insurance Number

Medicaid Eligibility (Required)

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

Dentist/Dental Home

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?

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 applying for the Head Start program. A staff member from our agency will contact you to complete the application process within 7-10 business days.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings