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Welcome! We’re happy you're here! This application helps us learn more about your child and family so we can determine eligibility for South Coast Head Start services. Please answer each question as completely and honestly as you can. If you are unsure about a question or do not have all the information right now, that’s okay. Please do your best, our staff is here to help. Completing this application does not guarantee enrollment. Once your application is submitted, our team will review it and contact you via EMAIL with next steps. If you have questions or need assistance at any time while completing this application, please call us at (541)888-3717. We are happy to support you

Custodial Guardian/Parent

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

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 (Required)

Home Phone (Required)

Work Phone (Required)

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 (Required)

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 (Required)

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

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)

Birthday (Required)

Gender (Required)

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 (Required)

Home Phone (Required)

Work Phone (Required)

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 (Required)

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 (Required)

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home

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?

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)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender (Required)

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

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

English Proficiency (Required)

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)

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 completing this application for South Coast Head Start. Once your application is received, it will be reviewed by our Enrollment Specialist (ERSEA). After your application is submitted, you will be contacted by email with next steps and information about the documents needed to continue processing your application. Please be sure to check your spam or junk folder for emails from us. Our team will also follow up with weekly phone calls to help complete the application process and answer any questions you may have. These documents may include: • Proof of birth for your child (such as a copy of a birth certificate or immunization record) • Income verification for all custodial adults, which may include a W-2, tax return, current pay stub, SSI, TANF, SNAP documentation, or a signed zero-income statement When a space becomes available, children are selected for enrollment from the waitlist based on selection criteria approved by our Policy Council, using information provided in applications. If you have questions or need help at any time, please call South Coast Head Start at 541-888-3717. We are happy to assist you!

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings