Thank you for your interest in early childhood education! We look forward to meeting with you. Please complete all of the following information for your children ages 0-5 and living in Berrien, Cass, and Van Buren Counties.
Parent/Guardian
Complete the following information for the parent or legal guardian.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Other
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
Yes
No
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.
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Address
Please enter the child's address of residence here.
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.
Additional Parent/Guardian
If there are two parents or legal guardians, please fill out the following information for the second adult.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Other
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
Yes
No
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.
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
Achi (Guatemala Dialect)
Akateco (Mexican Dialect)
Aketek (Guatemala Dialect)
Albanian
American Sign Language
Amharic
Andalusian (Spanish Dialect)
Andean (Spanish Dialect)
Arabic
Armenian
Awakatek (Guatemala Dialect)
Azeri
Basque (Spanish Dialect)
Bengali
Bosnian/Croation
Bulgarian
Burmese
Canarian (Spanish Dialect)
Caribbean (Spanish Dialect)
Castilian (Spanish Dialect)
Catalan (Spanish Dialect)
Central American (Spanish Dialect)
Chinese (Cantonese)
Chinese (Fujianese)
Chinese (Mandarin)
Ch'orti' (Guatemala Dialect)
Chuj (Guatemala Dialect)
Czech
English
Equatoguinean (Spanish Dialect)
Estonian
Extremaduran (Spanish Dialect)
Farsi
French
Galician (Spanish Dialect)
Garífuna (Guatemala Dialect)
Georgian
German
Gujarati
Hausa
Hebrew
Hindi
Hungarian
Ibo
Indonesian
Itza (Guatemala Dialect)
Ixil (Guatemala Dialect)
Jakalteco (Mexican Dialect)
Jakaltek (Guatemala Dialect)
K´iche (Guatemala Dialect)
Kaqchikel (Guatemala Dialect)
Kazakh
Khmer (Cambodian)
Kinyarwanda
Korean
Kurdish
Latin American (Spanish Dialect)
Latvian
Lingala
Lithuanian
Llanito (Spanish Dialect)
Macedonian
Malay
Mam (Guatemala Dialect)
Marathi
Mexican (Spanish Dialect)
Mongolian
Mopan (Guatemala Dialect)
Murcian (Spanish Dialect)
Nepali
Other
Palauan
Panjabi
Polish
Poqomam (Guatemala Dialect)
Poqomchi (Guatemala Dialect)
Portuguese
Pushto
Q´eqchi´ (Guatemala Dialect)
Qánjob´al (Guatemala Dialect)
Rioplatense (Spanish Dialect)
Romanian
Russian
Sakapulteco (Mexican Dialect)
Sakapultek (Guatemala Dialect)
Serbian
Shona
Sinhalese
Sipakapa (Guatemala Dialect)
Sipakapense (Mexican Dialect)
Slovak
Somali
Spanish
Swahili
Tagalog
Tamil
Tektitek (Guatemala Dialect)
Tektiteko (Mexican Dialect)
Telagu
Thai
Tigrignia
Turkish
Twi
Tz´utujil (Guatemala Dialect)
Ukranian
Urdu
Uspantek (Guatemala Dialect)
Uspanteko (Mexican Dialect)
Uzbeck
Vietnamese
Xincan languages (Guatemala Dialect)
Yoruba
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
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Other
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)
Early Head Start 2023-2024 School Year
Year Round Services for Ages 0-3
Head Start 2023-2024 School Year
Preschool Services for Ages 3-5 (Must be 3 by September 1, 2023)
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
Thank you for providing this information about your family. A Family Advocate will be in contact with you to schedule an application interview and determine eligibility. If your family is not eligible for Tri County Head Start services, this information will be shared with other early childhood education agencies in our community, in order to provide services to as many families as possible. In the event that you are unable to submit this application, please call 1-800-792-0366 and our staff can help assist you.
Required information is missing, see above.