Welcome! Here families can begin the pre-application for Douglass Community Services Head Start/Early Head Start/Child Care Partnership if they are interested in services for their 0-5 year old child or for themselves if they are a pregnant woman. Our program is a family oriented program that focuses on comprehensive services for school readiness. Our program has both home and center based services, and parents are an important part of everything our program does! 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!
Parent/Guardian
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
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 (Required)
Opt In for Text Messages
Yes
No
Home Phone (Required)
Work Phone (Required)
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
Lives with Family
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Asian
English
European
other
Sign Language
Spanish
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full Time (20 hours/week or more)
Full-time & Training
Part Time (Under 20 hours/week)
Part-time & Training
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Address
Please list your mailing address and physical address below.
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
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?
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
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.
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
Lives with Family
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Asian
English
European
other
Sign Language
Spanish
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full Time (20 hours/week or more)
Full-time & Training
Part Time (Under 20 hours/week)
Part-time & Training
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Provides Financial Support
Yes
No
Other Adults
Are there other adults in the household?
Add Another Adult
Family Information
This section refers to your family as a unit. If you are unsure of a question, please leave it blank.
Primary Language at Home
American Sign Language
Asian
English
European
other
Sign Language
Spanish
Spanish
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)
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
Female
Male
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 2024-2025
Head Start 2025-2026
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd 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 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.