Early Head Start Application



  • Enter Your Child's Name:


  • First Name: (Required)
    MI:
    Last Name: (Required)

  • Date of Birth:

  • Gender:



  • P.O. Box:

  • Address:
    City:
    State:
    ZIP:

  • Home Phone:
    E-mail:
    Cell Phone:
    Contact Preference:

  • Medical Coverage:






  • Does your child have difficulty with:






  • Does the public school or another agency have an IEP (Individual Education Plan) written on your child? If yes who:

  • Mother's Name:

  • Mother's Date of Birth:

  • Lives with Child:



  • Employed:



  • Name of Employer:

  • Date of Hire:

  • Enrolled in:




  • Father's Name:

  • Father's Date of Birth:

  • Lives with Child:



  • Employed:



  • Name of Employer:

  • Date of Hire:

  • Enrolled in:




  • Sibling Living in the Home:

  • Date of Birth:

  • Sibling Living in the Home:

  • Date of Birth:

  • Sibling Living in the Home:

  • Date of Birth:

  • Sibling Living in the Home:

  • Date of Birth:

  • Others living in home and relationship to applicant::

  • Sources of Income for Family:








  • Do you receive Food Stamps:



  • How did you hear about Head Start: