Apply Online

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. 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.

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

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.

Mailing Address same as Living Address

Mailing Address

Address Line 2

City

State

ZIP

The secondary adult is related to the child through blood/marriage/adoption who lives 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

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 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?

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?

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Primary Health Coverage

Other 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

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.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings