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HS/EHS Application
Please fill out all fields to submit a pre-application. After you have submitted your information, a Family Services Worker will contact you to schedule an appointment to complete the application process.
Eligible Children Information
Child's Name
(Required)
First
Middle
Last
Birthday
(Required)
MM slash DD slash YYYY
Gender
Female
Male
I prefer not to say
Child's Race
American Indian or Alaska Native
Asian
Black or African American
White
Two or more races
Native Hawaiian or Other Pacific Islander
Other
Unspecified
Child's Ethnicity
Hispanic
Non-Hispanic
Is English your first language?
(Required)
Yes
No
If no, what is your first language?
Program Option Applying for:
(Required)
Home-Based
Early Head Start
Head Start
Professionally diagnosed disability, special health/ dietary concern, or food allergy?
(Required)
Yes
No
If yes, please explain:
Mother / Guardian Information
Mother / Guardian Name
(Required)
First
Middle
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
Female
Male
I prefer not to say
Home Phone
Cell Phone
Email
(Required)
Enter Email
Confirm Email
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Are you the natural parent of the child?
(Required)
Yes
No
If no, what is your relationship?
Father / Guardian Information
Name
First
Middle
Last
Address if different from above:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
I prefer not to say
Phone
Are you the natural parent of the child?
Yes
No
If no, what is your relationship?
The information requested is needed to help us establish your family's eligibility for the program. Please be advised this application is strictly confidential and voluntary. Any information regarding sex, education, or disability is gathered for statistical purposes only. This agency does not discriminate in any way in provision of services.