Please indicate interest in Early Head Start (Pregnancy to Age 3 home visit program) or Head Start (Ages 3-4) and Great Start Readiness Program (Age 4) preschool program. Children must be age 3/4 on or before December 1st of the school year to be eligible for preschool. Completion of this interest form does not guarantee your child will be served by a publicly funded preschool program. As part of the application process you will need to provide: • Proof of birth • Annual income/eligibility documentation IMPORTANT: If, after you enter your email address, you receive a message indicating that you have previously submitted an application, please contact Community Action Agency, Wendy Ketchens at 517-888-3768 or email wketchens@caajlh.org. This message indicates that you are already in our database and staff need to update your information via phone or email.
Parent/Guardian
A note about Family Size - please enter all individuals, living in the same household that are related to the enrolling child by blood, marriage or adoption.
First Name (Required)
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.
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
Doctoral Degree
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
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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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)
Last Name (Required)
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.
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
Doctoral Degree
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
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Family Information
If you have zero income, please enter as $1 dollar.
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
Asian
Chinese
English
Filipino
French
Indian
Italian
Japanese
Punjabi
Spanish
Tamil
Vietnamese
Yukrainian
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 under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Child (Applicant)
If your child has an IEP (Individualized Education Plan) or IFSP (Individualized Family Service Plan) please select "yes" for the question "Does your child have a disability?" In the note area, please provide information about your child's specific needs. If you are a pregnant mother applying for Early Head Start, please enter parents information for First Name, Last Name, and Date of Birth.
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
Asian
Chinese
English
Filipino
French
Indian
Italian
Japanese
Punjabi
Spanish
Tamil
Vietnamese
Yukrainian
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)
2023-2024 School Year
2024-2025 School Year
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
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 Jackson County early childhood programming. By completing and submitting this form you are giving permission for Community Action Agency (Head Start/Early Head Start) or Jackson Intermediate School District (GSRP) to contact you regarding your child's potential eligibility for the Early Head Start, Head Start, and Great Start Readiness Programs. If you appear to be eligible for Head Start or Early Head Start you will receive a call from Community Action Agency to schedule an application appointment. If you appear to be eligible for the Great Start Readiness Program (GSRP) you will receive a phone call to set up an eligibility verification appointment. If you have any questions about this form or experience any problems while completing it, please contact Community Action Agency, Wendy Ketchens at 517-888-3768 or email wketchens@caajlh.org. Parent Certification Statement: I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action.
Required information is missing, see above.