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Early Head Start and Head Start Program Application

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Please enter the applicants name.
Are you the legal guardian of the applicant?
Please enter the child's age
What is your relationship to the applicant?
Primary Caregiver information
Please Enter the Primary Caregivers First Name
Please Enter the Primary Caregivers Middle Name
Please Enter the Primary Caregivers Last Name
Please provide your email address.
Please provide the Primary Guardians Date of Birth
Please provide the primary guardians gender
Is the primary guardian Hispanic or Latino?
Please provide the Primary Caregivers Social Security Number
Please Provide the Primary Caregivers Race
Please Provide the Primary Caregivers Nationality
Does the Primary Caregiver have a disability?
Please enter your mailing address.
Please enter your city.
Please select your state.
Please enter your ZIP code.
Please enter the county of the Primary Caregiver.
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Please provide the primary caregivers home phone number
Please provide the primary caregivers cell phone number
Please provide the primary language spoken in your home.
Please provide the other language you speak in the home.
Please provide the secondary language spoken in your home.
Please provide the other language you speak in the home.
Please provide the primary caregivers English abilities
Please select your occupational status.
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Name of School Attending You're Attending.
Please provide your highest level of completed education.
Please provide any other education you have
Please enter your last grade completed
Are you currently on active duty in the military?
Are you currently on active duty in the military?
Are you a Veteran of the U.S. Military?
Please provide the number of people living in your Household.
Please provide your Medical Insurance information
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Please provide your Type of Housing.
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How long have you lived at your current address?
Provide your Housing Payment Arrangement
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Please tell us how many times have you moved in the past 12 months?
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Type of Federal or Other Assistance Received: (Choose ALL that apply)
Are you receiving SNAP? (Supplemental Nutrition Assistance Program, Food stamps)
Are you receiving WIC? (Women, Infants, and Children)
Are you receiving LIHEAP? (Low Income Home Energy Assistance Program)
Are you receiving TANF? (Temporary Assistance for Needy Families)
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Secondary Caregiver
Please let us know if there is a secondary caregiver.
Please Enter the Secondary Caregivers First Name
Please Enter the Secondary Caregivers Middle Name
Please Enter the Secondary Caregivers Last Name
Please provide the Secondary Guardians Date of Birth
Please provide the secondary guardians gender
Is the secondary guardian Hispanic or Latino?
Please provide the Secondary Caregivers Social Security Number
Please Provide the Secondary Caregivers Race
Please Provide the Secondary Caregivers Nationality
Does the Secondary Caregiver have a disability?
Please enter the county of the Secondary Caregiver.
Provide a work phone number.
Please provide the secondary caregivers cell phone number
Are you the legal guardian of the applicant?
What is your relationship to the applicant?
Please select your occupational status.
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Please provide the school you are attending
Please provide your highest level of completed education.
Please provide any other education you have
Please enter your last grade completed
Are you currently on active duty in the military?
Are you a Veteran of the U.S. Military?
Please provide your Medical Insurance information
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Child Data (Applicant)
Please Enter the Childs First Name
Please Enter the Childs Middle Name
Please Enter the Childs Last Name
Please provide your Childs Nickname.
Please provide the Childs Date of Birth
Please provide the Childs gender
Is the Child Hispanic or Latino?
Please provide the Childs Social Security Number
Please Provide the Childs Race
Please Provide the Childs Nationality
Does the child have a disability?
Please provide the Childs Health Insurance Carrier
Center Prefered
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Second Child Data (Applicant)
Please Enter the Childs First Name
Please Enter the Childs Middle Name
Please Enter the Childs Last Name
Please provide your Childs Nickname.
Please provide the Childs Date of Birth
Please provide the Childs gender
Is the Child Hispanic or Latino?
Please provide the Childs Social Security Number
Please Provide the Childs Race
Please Provide the Childs Nationality
Does the child have a disability?
Please provide the Childs Health Insurance Carrier
Center Prefered
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Please enter the best time for a follow-up appointment.
Additional Household Members:
Please select if there's an additional person.

Household Member 1

Please Enter the adults First Name
Please provide the adults Date of Birth
Please Provide the adults Race
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional person.

Household Member 2

Please Enter the adults First Name
Please provide the adults Date of Birth
Please Provide the adults Race
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional person.

Household Member 3

Please Enter the adults First Name
Please provide the adults Date of Birth
Please Provide the adults Race
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional adult.

Household Member 4

Please Enter the adults First Name
Please provide the adults Date of Birth
Please Provide the adults Race
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional adult.

Household Member 5

Please Enter the adults First Name
Please provide the adults Date of Birth
Please Provide the adults Race
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional adult.

Household Member 6

Please Enter the adults First Name
Please provide the adults Date of Birth
Please Provide the adults Race
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional person.

Household Member 7

Please Enter the adults First Name
Please Provide the adults Race
Please provide the adults Date of Birth
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional person.

Household Member 8

Please Enter the adults First Name
Please Provide the adults Race
Please provide the adults Date of Birth
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Please select if there's an additional person.

Household Member 9

Please Enter the adults First Name
Please Provide the adults Race
Please provide the adults Date of Birth
Please provide the adults Social Security Number
Please Enter the adults Middle Name
Please provide the adults gender
Please Provide the adults Nationality
Provide a work phone number.
Please Enter the adults Last Name
Is the secondary guardian Hispanic or Latino?
Does the Secondary Caregiver have a disability?
What is your relationship to the applicant?
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Please select whether or not this person is attending school.
Please provide the school the adult is attending
Please enter the last grade completed
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Family Residency Questionnaire

As of December 12, 2007, with the passage of the Head Start Reauthorization Act of 2007, a11y child whose current housing situatio11 entitles them to services under section 725(2) of the McKinney-Ve11to Act (42 U.S.C 11435(2) is considered automatically eligible for Head Start services. Eligibility may be determi11ed by completing this questionnaire.

This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C 11435. The answers to this residency information help determine whether the child may automatically eligible for Head Start services.

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I certify that the information I have given is correct to the best of my knowledge. I understand that if the program determines that my child does not automatically qualify for Head Start services under the McKinney-Vento Act, acceptance into the program will be decided based on the program's current child eligibility criteria.

Please provide your digital signature
Social Service Need Questionnaire

The goal of our program is to provide services to the families who need it the most. If any of the following apply to your family, please check the box below and provide a brief description of the situation. In an of these circumstances apply, one of our Family Services Specialists will reach out to you via email or phone to request an interview.

Please select an option. If None of these apply please select that box
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Digital Verification Signature:

I certify that the information provided in this application, and the income indicated for enrollment eligibility, are accurate and truthful to the best of my knowledge. Providing false income/information could result in dismissal from the program and may be subjected to legal action. I also understand that the information given to the program will remain confidential and is accessible to me during normal business hours.

Please provide your digital signature