Parent/Guardian
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
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
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
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
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
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?
Referred By (Required)
DCFS
Delegate Agency Website
Flyer
Google Search
Internet Advertisement
LA-211
Medical Office/Community Partner
Pre-K Kid Referral
Previous/Returning Family
Public Service Announcement
Recruitment/Community Event
Regional Center
Social Media
Walk in
WIC
Word of Mouth
Location Preferences
Which program are you applying for? (Required)
Head Start
For Children Ages 3 to 5
Early Head Start
For Children Ages 0 to 3
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
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to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Required information is missing, see above.