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Currently Enrolled / Previously Applied
If you have a child currently enrolled, previously enrolled or your family has previously completed an application in the Head Start or Early Head Start Program, please do not complete an online application. Contact your local Head Start/Early Head Start Office through email at application@region10.org and include your child's name, date of birth, the district you reside, telephone number and contact e-mail address and a Head Start/Early Head Start staff member will get back to you as soon as possible.

New Applicant Only
This is the first step in the process of completing the Head Start/Early Head Start (HS/EHS) application. Please complete the brief online application below and be sure to enter a contact phone number and email address.

If you are currently pregnant and applying for the Early Head Start program, and have a child currently enrolled or was previously enrolled in the Head Start or Early Head Start Program, please do not complete an online application. Contact your local Head Start/Early Head Start Office through email at application@region10.org and include your child's name, date of birth, the district you reside, telephone number and contact email address and a Head Start/Early Head Start staff member will get back to you as soon as possible.

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

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 (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 (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent (Required)

Physical Address, No P.O. Box.

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

Mother, Father, Legal Guardian of child applicant

Is there another parent/guardian in the family?

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

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 (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 (Required)

English Proficiency (Required)

Other Language

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent (Required)

Are there other adults in the household?

Add Another Adult

Please answer the following questions for individuals who are supported by the family income.

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home? (Required)

Number in Family (Required)

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?

Add Emergency Contact

Currently Enrolled / Previously Applied
If you have a child currently enrolled, previously enrolled or your family has previously completed an application in the Head Start or Early Head Start Program, please do not complete an online application. Contact your local Head Start/Early Head Start Office through email at application@region10.org and include your child's name, date of birth, the district you reside, telephone number and contact e-mail address and a Head Start/Early Head Start staff member will get back to you as soon as possible.

If your child has been identified with a developmental delay (e.g., speech, occupational, or physical) through a district or private evaluation, or if you or your physician have any developmental concerns, kindly provide details in the section below labeled 'Is there anything else you want to tell us about your child?’

First Name (Required)

Middle Name

Last Name (Required)

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

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Insurance Number

Medicaid Eligibility (Required)

Medicaid Number

Dental Coverage (Required)

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?

How did you hear about us (Required)

Other, Describe

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

Certification: I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.

Thank you for your interest in the Head Start/Early Head Start (HS/EHS) program. You will receive an email confirming your application. The Head Start / Early Head Start staff will notify you soon.

Please note the documents needed to complete enrollment:
*Child’s Birth Certificate,
*Immunization Record,
*Proof of Income (Current: Taxes, 1040 with all W-2's, Pell Grant, Pell Grant, TANF, SNAP),
*Proof of Public Assistance/Services (TANF, SNAP, SSI),
*Proof of Residency (Utility bill with name and address)
*Documentation of Child’s Disability/ARD (if applicable)

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