If you would like to take an application for the sibling of a currently enrolled child, please do not fill out this application. Please contact your local center or Central Office at 573-454-2200. If you have already applied at a center and have moved to a center in our eight county area, please call our office, there is no need for an additional application. This is a preliminary application for the Head Start program. Before an application will be considered for enrollment, we must have a copy of the child's birth certificate and 12 months proof of income. Once an application is submitted, a staff member will call/email you in order to receive the appropriate documents to complete this application. Please note, all children that are age and income eligible are placed on a waitlist once all information is verified. Children must have turned 3 before August 1st, 2020 and not turn 5 until after August 1, 2020, in order to be eligible for the 2020-2021 program year. We will pick off of the waitlist until April 2021. We only accept applications in our service area. We services the following counties: Bollinger, Cape Girardeau, Iron, Madison, Perry, St. Francois, Ste. Genevieve and Washington Counties in Missouri.
Parent/Guardian
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
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
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
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
AFRICAN (Swahili, Wolof)
American Sign Language
CARIBBEAN (Haitian-Creole, Patois)
EAST ASIAN (Chinese, Vietnamese, Tagalog)
English
EUROPEAN & SLAVIC (German, French, Italian, Croatian, Yiddish, Portuguese, Russian)
MIDDLE EAST & SOUTH ASIAN (Arabic, Hebrew, Hindi, Urdu, Bengali)
NATIVE CENTRAL AMERICAN, SOUTH AMERICAN & MEXICAN (Mixteco, Quichean)
NATIVE NORTH AMERICAN/ALASKA NATIVE
PACIFIC ISLAND (Palauan, Fijian)
SINHAL (SRI-LANRAN)
SPANISH
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Disabled
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
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
The secondary adult is related to the child through blood/marriage/adoption.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
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
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
AFRICAN (Swahili, Wolof)
American Sign Language
CARIBBEAN (Haitian-Creole, Patois)
EAST ASIAN (Chinese, Vietnamese, Tagalog)
English
EUROPEAN & SLAVIC (German, French, Italian, Croatian, Yiddish, Portuguese, Russian)
MIDDLE EAST & SOUTH ASIAN (Arabic, Hebrew, Hindi, Urdu, Bengali)
NATIVE CENTRAL AMERICAN, SOUTH AMERICAN & MEXICAN (Mixteco, Quichean)
NATIVE NORTH AMERICAN/ALASKA NATIVE
PACIFIC ISLAND (Palauan, Fijian)
SINHAL (SRI-LANRAN)
SPANISH
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Disabled
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Primary Language at Home
AFRICAN (Swahili, Wolof)
American Sign Language
CARIBBEAN (Haitian-Creole, Patois)
EAST ASIAN (Chinese, Vietnamese, Tagalog)
English
EUROPEAN & SLAVIC (German, French, Italian, Croatian, Yiddish, Portuguese, Russian)
MIDDLE EAST & SOUTH ASIAN (Arabic, Hebrew, Hindi, Urdu, Bengali)
NATIVE CENTRAL AMERICAN, SOUTH AMERICAN & MEXICAN (Mixteco, Quichean)
NATIVE NORTH AMERICAN/ALASKA NATIVE
PACIFIC ISLAND (Palauan, Fijian)
SINHAL (SRI-LANRAN)
SPANISH
Number in Household
Number in Family
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Emergency Contacts
Add Emergency Contact
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
AFRICAN (Swahili, Wolof)
American Sign Language
CARIBBEAN (Haitian-Creole, Patois)
EAST ASIAN (Chinese, Vietnamese, Tagalog)
English
EUROPEAN & SLAVIC (German, French, Italian, Croatian, Yiddish, Portuguese, Russian)
MIDDLE EAST & SOUTH ASIAN (Arabic, Hebrew, Hindi, Urdu, Bengali)
NATIVE CENTRAL AMERICAN, SOUTH AMERICAN & MEXICAN (Mixteco, Quichean)
NATIVE NORTH AMERICAN/ALASKA NATIVE
PACIFIC ISLAND (Palauan, Fijian)
SINHAL (SRI-LANRAN)
SPANISH
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Program Year 2020-2021
Free Pre-School for Children 3 to 5 years of age (Must turn 3 before July 31, 2020 and 5 after July 31, 2020)
1st Location Preference
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2nd 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 for taking an application with our program! Once you have hit submit, our staff will call/email you within 2/3 business to complete the application.
Required information is missing, see above.