Apply Online

Thank you for your interest in the Early Head Start and/or Head Start program. Please complete all the "required" boxes and provide a phone number and email where we can reach you at. This will ensure your child's application is processed.

First Name (Required)

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

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

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

Hispanic

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Lives with Family

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

Address Line 2

City

State

ZIP

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Suffix

Birthday (Required)

Gender

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

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

Hispanic

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Lives with Family

Provides Financial Support

Teen Parent

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Number in Household

Number in Family

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

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

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

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

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

First Name (Required)

Last Name (Required)

Nickname

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Doctor/Medical Home

Dental Coverage

Dentist/Dental Home

Does your child have a disability or do you have any concerns about your child's development?

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

Which program are you applying for? (Required)

1st Location Preference

2nd 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

Thank you for your interest in the Early Head Start and/or Head Start program. Parent Certification: By click "submit" you are accept Early Head Start and/or Head Start services and certify that is information is true. If any part is false, my participation in this agency's program may be terminated. I also understand that the information on this application will be held in strict confidence within the agency and is accessible to me during normal business hours. Someone will contact you to schedule an application interview. If you do not hear from us within 5 days from the submission of your application, contact the main office at 808-245-5914.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings