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This is the Douglass Community Services Head Start/EHS/CCP interest information worksheet. Here you can begin the process if you are interested in services for your 0-5 year old child or for yourself if you are a pregnant woman. We are a family oriented program that focuses on comprehensive services for school readiness. We have both home and center based services, and parents are an important part of everything we do! Please complete the information below. Once we receive the interest worksheet, we will contact you. We will need to get copies of your income information and your child's immunizations. We will want to see your child's birth certificate (or other documentation) and health insurance information. Don't worry if you don't have these documents. We will help you get them! If your child has special needs, be sure to let us know! We will review your child's IFSP or IEP and work with you on those goals! Thank you for your interest in our program!

This section is information on the primary adult in the family. This must be the child's legal parent, guardian or foster parent. If you do not have an email address please list hs@dcs.org as a default. If you are unsure of a question, please leave it blank.

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

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Please list your mailing address and physical address below.

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

This section is for the secondary adult in the family (if applicable) The secondary adult must be related to the child by blood, adoption, or guardianship. Step parents can be secondary adults. If you are unsure of a question, please leave it blank.

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

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Are there other adults in the household?

Add Another Adult

This section refers to your family as a unit. If you are unsure of a question, please leave it blank.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Number in Household

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

This section is information on the applying child. If you are unsure of a question, please leave it blank.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

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 completing this interest survey. Someone will contact you within one week to do your application. They will verify the information and get copies of your income and your child's immunizations. Please call 573-221-3890 ext. 238 or 1-800-530-5016 ext 238 if you do not hear from a staff person within one week.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings