Instructions: Please fill out all questions asked in the application. Once you have completed the entire application, you will receive an email confirming your child’s application from your preferred Head Start location. You will be notified of Registration Events for JeffCAP Head Start with a list of required documents needed. Any child in a publicly funded “seat” must also apply to Jefferson Child: www.jeffersonchild.com
Parent/Guardian
Please answer questions about education, employment and income based on the date of the application. For teen parents, only enter 'Yes' if 19 years or younger on the date of application.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
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
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)
Click here
to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Family Information
For TANF, SSI WIC or SNAP only answer "Yes" if you are currently receiving those benefits. Proof of Income and copies of awards letters will be requested.
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
Chinese
English
French
French/Creole
Gujarati - India
Hindi
IBO - Nigeria
Portuguese
Russian
Spanish
Urdu
Vietnamese
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
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
Child (Applicant)
If your child has an IEP or IFSP, please attach the document include the services begin and end dates in the notes section below.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latino
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
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)
JeffCAP Head Start 2023-2024 School Year
Head Start Program for children age 3 - 5 years old
JeffCAP Early Head Start 2023-2024 School Year
Early Head Start for children 6 weeks - 35 months
JeffCAP Early Head Start 2023-2024 School Year
Early Head Start for children 6 weeks - 35 months
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
You will receive an email confirmation once the application is submitted. We will contact you to schedule an appointment to complete the registration process. You are responsible for updating contact information if it changes. We will only use the numbers and addresses submitted to notify you of your child's status.
Required information is missing, see above.