Apply Online

Please fill out this application in its entirety!

Please provide your information. This will be the primary point of contact for application status updates !

First Name (Required)

Middle Name

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

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 (Required)

Hispanic (Required)

Lives with Family

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status

Child's Relationship

Custody

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Please provide your current and valid mailing and living address.

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

Are there other adults in the household?

Add Another Adult

We would like to know more about your family!

Number of Parents/Guardians (Required)

Relationship to Participant(s)

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?

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

WIC ID (if applicable)

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

Please provide information about the child you are interested in attending the program.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

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?

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 our Head Start program. We will be in contact with you in the coming weeks regarding the status of your application.

Required information is missing, see above.

Parent/Guardian

Address

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings