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Thank you for your interest in Inter-Lakes Head Start Pre-Birth to Five Program. Head Start/Early Head Start serves children and families that reside in Clark, Grant, Codington, Hamlin, Deuel, Kingsbury, Brookings, Miner, Lake, Moody, McCook, and Minnehaha. Our program provides educational, health, and family services to expectant women and children up to age 5 and their families. It is a federally funded and free to income - eligible families. Please complete the following information. If anyone in your family has previously applied to our program, please stop and email dJensen@interlakescap.com and leave your name and number to contact. We look forward to hearing from you! • We will need 12 months' worth of your household income. o Examples: Federal Tax Form from the previous year, W-2's from all jobs held the previous year, SNAP, TANF, Supplemental Security Income (SSI) Statement, child support or Paystubs showing the last 12 months. Please also have your child's immunizations and state birth certificate available.

First Name (Required)

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

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 and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support

Teen Parent

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 (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

ONLY list if living in household

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

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

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 and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Teen Parent

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home? (Required)

Number in Household (Required)

Number in Family (Required)

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Is at least one parent/guardian an active duty member of the United States military? (Required)

Is at least one parent/guardian a veteran of the United States military? (Required)

Add Emergency Contact

In application notes please list any allergies or medical concerns your child may have.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender (Required)

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Doctor/Medical Home

Dentist/Dental Home

Is there anything else you want to tell us about your child?

Child has IEP or IFSP

How did you hear about us

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

You will receive an email confirmation once the application is submitted. We will contact you soon.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings