Parent/Guardian
First Name (Required)
Last Name (Required)
Birthday (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
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.
English Proficiency
Little
Moderate
None
Proficient
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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Family Information
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
Asian Languages
Chinese
English
Japanese
Korean
Mongolian
Native American Languages
Other
Spanish
Spanish
Unspecified
Number in Family
Gross Annual Income
Child (Applicant)
First Name (Required)
Last Name (Required)
Birthday (Required)
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Early Head Start 2024-2025
Head Start - 2024-2025
Early Head Start 2025-2026
Head Start - 2025-2026
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- Your Address
- Available Locations
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Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Required information is missing, see above.