Head Start Application English

Parent/Guardian

First name

Middle name

Last name

Birth Day

Gender

Email Address

Confirm Email Address

Mobile Phone

Home Phone

Work Phone

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

Address

Is your family experiencing homelessness?

Living Address

Address Line 2

City

State

Zip

Mailing Address same as Living Address

Additional Parent/Guardian

Is there another parent/guardian in the family?

Other Adults

Are there other adults in the household?

Family Information

Number of Parents/Guardians

Primary Language at Home

Number in Household

Number in Family

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?

WIC ID (if applicable)

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?

Child (Applicant)

This application can also be filled out for mothers who are pregnant. If you are applying as a pregnant mother, please put the new child's first and last name and the anticipated date of birth for your child where required.

First name

Middle name

Last name

Suffix

Nickname

Birth Day

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

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?

Location Preferences

Which program are you applying for? (Required)

Additional Applicant

Do you want to apply now for another child in your family?

Siblings

Are there other children in the family?