Parent/Guardian
Please complete the questions below. Check the Teen Parent box if you are under the age of 18. Check the Teen Parent subsidized box if you are participating in a program designed specifically for teen parents.
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender (Required)
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.
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
PhD
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
In School
Job Training
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Address
Please include apartment/building/lot number, direction (Southeast, Northeast, etc) if applicable.
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
Please complete the questions below. Check the Teen Parent box if you are under the age of 20. Check the Teen Parent subsidized box if you are participating in a program designed specifically for teen parents.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Suffix
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.
Lives with Family
Yes
No
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
In School
Job Training
Part-time & Training
Part-time (Under 35 hours/week)
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
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Family Information
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
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
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
English Proficiency
Little
Moderate
None
Proficient
Other Language
African
African French
African Languages
African Sonike
American Sign Language
Amharic
Arabic
Burmese (Chin)
Caribbean Languages
Central American
Chinese
Creole
East Asian
English
French
Greek
Hmong
Kurdish
Laos
Middle Eastern & South Asian Languages
Native American-North Amer/Alaska Native
Nepalese
No Other Language
Oromo
Other
Pacific Island Languages
Pashto
Portuguese
Somali
Spanish
Swahili
Tigre
Ugandanese
Unspecified - Unknown/Parents Declined
URDU
Vietnamese
Wester European Languages
Yoruba
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
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)
Aug 2025-July 2026 Early Head Start (Richmond Coun
Free preschool for children ages 0 to 3
Aug 2025-July 2026 Early Head Start NE/Metro Atl
Free preschool for children ages 0 to 3 and pregnant women.
Aug 2025-May 2026 Head Start NE/Metro Atl
Free preschool for children ages 3 to 5
Aug 2025-May 2026 Head Start (Richmond County)
Free preschool for children ages 3 to 5
Location Preference
<p></p>
1st Location Preference
<p></p>
2nd Location Preference
<p></p>
3rd Location Preference
<p></p>
- 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
Siblings
Are there other children in the family?
Add a Sibling
Required information is missing, see above.