Please fill in the form completely and accurately. All information will be kept confidential. It will be used to help us determine if your family is eligible for services.
If you have any questions about this pre-application, or need any help in completing it, please call us at 541-747-2425. We will be glad to help!
Parent/Guardian
First Name (Required)
Middle Name
Last Name (Required)
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
Home Phone
Work Phone
Ext.
English Proficiency
Little
Moderate
None
Proficient
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
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
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Mobile Phone
Home Phone
Work Phone
Ext.
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Child (Applicant)
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Amharic
Arabic
Armenian
Bambara French
Bengali
Burmese
Chinese, Cantonese
Chinese, Mandarin
Creole
Croatian
English
Farsi / Persian
Filipino / Tagalog
French
German
Hebrew
Hindi
Hmong / Mong
Japanese
Kachin
Khmer
Korean
Mam
Mixtec
Myanmar
Nahuatl / Aztec
Nepali
Other (Email language to mgroesbeck@hsolc.org)
Punjabi
Rawang
Russian
Samoan
Somali
Spanish
Tigrinya
Tongan
Twi
Ukrainian
Vietnamese
Wolof
Zapotec
Other Language Proficiency
Little
Moderate
None
Proficient
Location Preferences
Which program are you applying for? (Required)
EHS (2019-20)
Early Head Start (2018-2019)
For pregnant mothers & children under age 3.
HS (2019-20)
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
Thank you for your interest in Head Start of Lane County! Please click Submit to finalize your pre-application. A member of our Eligibility Department will contact you.
Required information is missing, see above.