Apply Online

Welcome to the online enrollment application for the Alabama-Coushatta Head Start Program! We are excited that you are interested in our program and look forwarded to getting to know you and your student/s as you complete the enrollment process. Once you complete this enrollment application the next step is an in-person intake appointment. At this appointment we will verify your eligibility and provide you with next steps.

Please fill out this section for the Primary Adult for your student. This is the person who provides the majority of financial support to the student and is the primary one responsible for the students' wellbeing.

First Name (Required)

Middle Name

Last Name (Required)

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

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.

SSN

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status (Required)

Child's Relationship (Required)

Custody

Provides Financial Support

Please provide both your mailing address and living address unless you have indicated homelessness.

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 (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

Please fill out this section for the Secondary Adult for your student. This is the second person who is responsible for your student and their wellbeing.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

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

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 and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship (Required)

Custody

Provides Financial Support

Are there other adults in the household?

Add Another Adult

Please help us understand your student's family.

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Number in Household (Required)

Number in Family (Required)

Gross Annual Income

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?

WIC ID (if applicable)

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?

Add Emergency Contact

Tell us about your student.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

SSN

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Medicaid Eligibility

Doctor/Medical Home

Dentist/Dental Home

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

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

Which program are you applying for? (Required)

Location Preference

1st Location Preference

2nd Location Preference

3rd 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 our Head Start Program. 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. At this appointment we will verify your eligibility and provide you with next steps. Documentation must be provided to verify eligibility. See the list in your confirmation email on what documents are needed.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings