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
Number of Parents/Guardians
One Parent Family
Two Parent Family
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
Primary Language at Home
African
American Sign Language
Arabic
Armenian
Burmese
Cantonese
Caribbean
Chaozhou (Chaochow)
English
European / Slavic
Hmong
Khmer
Korean
Lao
Mandarin
Middle Eastern and South Asian
Native Central, South American, Mexican
Native North American/Alaskan
Other Languages of China
Other non-English
Pacific Island
Pilipino
Rumanian
Spanish
Taiwanese
Thai
Toishanese
Unspecified
Vietnamese
Number in Family
Gross Annual Income
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?
Location Preferences
Which program are you applying for? (Required)
Head Start
For Children Ages 3 to 5
Head Start
For Children Ages 3 to 5
Early Head Start
For Children Ages 0 to 3
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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Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Required information is missing, see above.