Welcome to the first step in getting a head start in your child's learning and development. Please fill out the information below and submit your application.
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.
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
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Dari
English
French
Hindi
Japanese
Kurdish
Malayalam
Mam
Pashto
Portuguese
Russian
Spanish
Swahili
Tamil
Turkish
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
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
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
Address
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
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Dari
English
French
Hindi
Japanese
Kurdish
Malayalam
Mam
Pashto
Portuguese
Russian
Spanish
Swahili
Tamil
Turkish
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
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
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
Lives with Family
Yes
No
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
American Sign Language
Arabic
Dari
English
French
Hindi
Japanese
Kurdish
Malayalam
Mam
Pashto
Portuguese
Russian
Spanish
Swahili
Tamil
Turkish
Number in Household
Number in Family
Gross Annual Income
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
WIC ID (if applicable)
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)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
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
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Arabic
Dari
English
French
Hindi
Japanese
Kurdish
Malayalam
Mam
Pashto
Portuguese
Russian
Spanish
Swahili
Tamil
Turkish
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Doctor/Medical Home
Amnulatory Care Center Bpt YNHCH
Birth to Three Services, CT
Birth to Three, CT
Branford Pediatrics
Branford/North Branford Pedi.
Butler/Davis/Wijesekera/Spiesel
chidl and adolescent healt care
Child &Adolescent Health CareLLC
Children Medical Group
Community Health Center
Complete Pediatrics
cook children pedi
Cornell Scott Hill Health Center
CT Birth to Three
East Haven Pediatrics
Elm Family Dental
Fair Haven Community Health Care
Fair Haven Community Health Clin
family health care
Hamden Pediatrics
Health Care Provider
Hill Health Center
Iman Ibrahim M.D
Jesus Pichardo, MD
LULAC Health PromotionSpecialist
LULAC Individual Support Sp.
LULAC Nurse Consultant
LULAC Nutrition Consultant
Maimonides Medical Center
Meriden Pediatrics Associates
Milford Pediatric Group
NEMG Family Medicine
New Britain Pediatric Group, P.C
New Haven Pediatrics
Newington Pediatrics
Norwalk Communinity Health
Open Door Family Medical Center
OPTIMUS HEALTHCARE
Orange Pediatrics
Pediatric & Adolescent Medicine
Pediatric & Medical Associates P
Pediatric Advanced Care Of WH
Pediatric Care Center,LLC
Pediatric Health Care Associates
Pediatric healthcare associates
Pediatric Plus
Pediatric Sleep Clinic
Pediatrics Assoc. of Brandford
Primary Care Pediatric
Shelton Pediatric, PLLC
Shoreline Family Health Care
Slocum-Dickson
Stay Well Health Care Inc
Stony Brooks Children Services
True Pediatric Dental Care
West Haven Pediatrics
Whitney Pediatric and Adolescent
Yale Chapel Pediatrics
Yale Health Center
Yale Primary Care (Fair Haven)
Yale Regional Lead Treatment
YNHH/ST. Raphael Campus
Dentist/Dental Home
12 Month Smiles
All Kids Dental
Big Smiles
Brandford Dental Care
Chapel Street Dental
Children Medical Group
Children's Dental Ass. of Hamden
Children's Dental Group
Clover Dental Care
Columbia Dental
Connect Family Dental
Connecticut Dental Associates
cornel scott
Dental Associates
Dental Care of Milford
Dental Department
Dental Prophy C/ Esthefly
Dixwell Dental
DMD Family Dentistry
Dr. Dental
Dr. Dental
Dr. Dental (Foxon Rd.)
Dr. Dental (Hamden)
Dr. Dental of New Haven
Dr. Dess
Dr.Lamberti
East Haven dentistry
Elm Family Dental
Elm Family Dental
Expert Dental
Fair Haven Community Health Care
Fair Haven Dental
Grand Dental
Haven Pediatric Dentistry
Health Med Dental Care
Hill Health Cornell Scott
Horizon Dental
Kids First Pediatric Dentistry
Long Wharf Dental Group
Long Wharf Pediatrics
Maimonides Dental
MCM Dental Group
New Haven Dental Associates
New Haven dental Group in Woodbr
New Haven Kids Dentistry
Nova Dental
Open Door- Dental
Parkway Dental
Pediatric Dentistry Assoc
Pediatric Dentistry Associates
Pedro Garcia
Pure Smiles
Roxana Jafarian DDS LLC
Shoreline Dental
Shoreline Family Health Care
Smart Dental LLC, Eduardo Cortes
Sound Dental
Star Dental
Sutton Dental and Braces
The Children Dental Group
True Pediatric Dental Care
Valley Dental
Vandilk Furino & Associates
Vaughn Family Dentistry
West Haven Dental
Westville Family Dentl
Wilton Dentist
Yale Health Center
Yale Pediatric Dental
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)
SR
Ages: 3 years-5 years
EHS
Ages: 2 months-3 years
1st Location Preference
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2nd 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
Siblings
Are there other children in the family?
Add a Sibling
Thank you for your interest in LULAC Head Start. By clicking the button below, you certify that the information you have provided is complete and accurate. We will contact you to set up an intake appointment. Please begin to gather the supporting documents needed to complete your application including: proof of income, proof of address, child's birth certificate, physical record, immunization record, dental exam, health insurance card.
Required information is missing, see above.