Early Head Start Enrollment Application

Early Head Start Enrollment Application

Please submit the following documents in order to apply for the Early Head Start Child Care Partnership seat. An application link will be sent to you upon document submissions.
How to save

You are able to save this form and return at a later date. Click the Save button at the bottom of the form to get a draft link.

Note a red asterisk symbol (*) indicates the field is required prior to submitting.
Parent/Guardian Information
Parent/Guardian's name*

First NameLast Name
Parent/Guardian's Date of Birth*

MonthDayYear
Date
Parent/Guardian's Gender*

FemaleMale
Parent/Guardian's Email Address*
example@example.com
Confirm Parent/Guardian's Email Address*
example@example.com
Mobile Phone*
Please enter a valid phone number.
Opt In for Text Messages*

YesNo
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Race*

American Indian or Alaskan NativeAsianBlack or African AmericanMulti-racial/BiracialNative Hawaiian/Other Pacific IslanderWhiteOther
Hispanic*

YesNo
English Proficiency

NoneLittleModerateProficient
Other Language

African LanguageAmerican Sign LanguageEnglishEuropean & Slavic LanguagesMiddle Eastern & South AsianSpanishOther
Other Language Proficiency

NoneLittleModerateProficient
Highest Grade Completed*

Associate's DegreeBachelor's DegreeCollege Degree/Training CertificateCollege or Advanced TrainingGeneral Education Diploma/Hi SETGrade 10Grade 11Grade 12Grade 9 or lessHigh School GraduateMaster's Degree
Employment Status*

Full-Time & TrainingFull-Time (35 hours/week or more)Part-Time & TrainingPart-Time (Less than 35 hours/week)Retired or DisabledSeasonally EmployedTraining or SchoolUnemployed
Child's Relationship

Biological/Adopted/StepFosterGrandchildOther RelativeOther
Custody

YesNo
Lives with Family

YesNo
Provides Financial Support

YesNo
Teen Parent

YesNo
Parent/Guardian Address
Is your family experiencing homelessness?*

YesNo
Living Address*
Address Line 2
City*
State*
ZIP*
Is the Mailing Address same as Living Address?*

YesNo
Mailing Address*
Mailing Address Line 2
Mailing Address City*
Mailing Address State*
Mailing Address ZIP*
Additional Parent/Guardian
Is there another parent or guardian in the family?

YesNo
Additional Parent/Guardian First Name*
Additional Parent/Guardian Last Name*
Additional Parent/Guardian Birthdate*

MonthDayYear
Date
Additional Parent/Guardian Gender

MaleFemale
Additional Parent/Guardian's Email Address*
example@example.com
Confirm Additional Parent/Guardian's Email Address*
example@example.com
Additional Parent/Guardian's Mobile Phone*
Please enter a valid phone number.
Additional Parent/Guardian's Opt In for Text Messages*

YesNo
Additional Parent/Guardian's Home Phone Number
Please enter a valid phone number.
Additional Parent/Guardian's Work Phone Number
Please enter a valid phone number.
Additional Parent/Guardian's Race*

American Indian or Alaskan NativeAsianBlack or African AmericanMulti-racial/BiracialNative Hawaiian/Other Pacific IslanderWhiteOther
Additional Parent/Guardian's Hispanic*

YesNo
Additional Parent/Guardian's English Proficiency

NoneLittleModerateProficient
Additional Parent/Guardian's Other Language

African LanguageAmerican Sign LanguageEnglishEuropean & Slavic LanguagesMiddle Eastern & South AsianSpanishOther
Additional Parent/Guardian's Other Language Proficiency

NoneLittleModerateProficient
Additional Parent/Guardian's Highest Grade Completed*

Associate's DegreeBachelor's DegreeCollege Degree/Training CertificateCollege or Advanced TrainingGeneral Education Diploma/Hi SETGrade 10Grade 11Grade 12Grade 9 or lessHigh School GraduateMaster's Degree
Additional Parent/Guardian's Employment Status*

Full-Time & TrainingFull-Time (35 hours/week or more)Part-Time & TrainingPart-Time (Less than 35 hours/week)Retired or DisabledSeasonally EmployedTraining or SchoolUnemployed
Additional Parent/Guardian's Relationship to Child*

Biological/Adopted/StepFosterGrandchildOther RelativeOther
Additional Parent/Guardian Has Custody*

YesNo
Additional Parent/Guardian Lives with Family*

YesNo
Additional Parent/Guardian Provides Financial Support

YesNo
Additional Parent/Guardian is a Teen Parent

YesNo
Other Adults
Are there other adults in the household?

YesNo
Other Adult #1's First Name*
Other Adult #1's Last Name*
Other Adult #1's Birthdate*

MonthDayYear
Date
Other Adult #1's Gender

MaleFemale
Other Adult #1's Mobile Phone*
Please enter a valid phone number.
Other Adult #1's Opt In for Text Messages*

YesNo
Other Adult #1's Home Phone Number
Please enter a valid phone number.
Other Adult #1's Work Phone Number
Please enter a valid phone number.
Other Adult #1's Relationship to Child*

Biological/Adopted/StepFosterGrandchildOther RelativeOther
Other Adult #1 Has Custody*

YesNo
Does the other Adult #1 Lives with Family*

YesNo
Family Information
Number of Parents/Guardians*

One Parent FamilyTwo Parent Family
Parent(s)/Guardian(s) Relationship to Child*

Parents (e.g., Biological, Adoptive, Stepparents)Foster Parent(s) not including relativesGrandparent(s)Relative(s) other than Grandparent(s)Other
Primary Language at Home*

African LanguageAmerican Sign LanguageEnglishEuropean & Slavic LanguagesMiddle Eastern & South AsianSpanishOther
Is another language being acquired or learned at home?

YesNo
Child's Information (Applicant)

Please only add children who are under the age of 3 on Sept 30, 2025.
Child's name*

First NameMiddle NameLast NameSuffix
Child's Nickname
Child's Date of Birth*

MonthDayYear
Date
Child's Gender*

FemaleMale
Child's Race*

American Indian or Alaskan NativeAsianBlack or African AmericanMulti-racial/BiracialNative Hawaiian/Other Pacific IslanderWhiteOther
Is child Hispanic*

YesNo
Child's Primary Health Coverage

Children's Health Insurance Program (CHIP)Combined Medicaid/CHIPMedicaidNo insurancePublic Health InsuranceState-Only Funded InsuranceOther
Child's Medicaid Eligibility

Not EligibleOn MedicaidPotentially Eligible
Does your child have a disability or do you have any concerns about your child's development?

YesNo
Is there anything else you want to tell us about your child?
Attachments to upload
Child's Birth Certificate*

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Child's Updated Shot Record (immunizations) *

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Parent ID (ex. Driver's license)*

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If applicable, Child Placement Agreement from DCSF or Provisional Custody by Mandate

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Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?*

YesNo
Please upload TANF documentation*

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Is your family receiving Supplemental Security Income (SSI)?*

YesNo
Please upload SSI documentation*

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Is your family receiving service under the supplemental Nutrition Assistance Program (SNAP), formerly referred to as food stamps?*

YesNo
Please upload SNAP documentation*

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Is your family receiving services from WIC?*

YesNo
Please upload WIC documentation*

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Is at least one parent/guardian an active duty member of the United States military

YesNo
Is at least one parent/guardian a veteran of the United States military

YesNo
Are you employed?*

YesNo
To prove your employment status, please submit one of the following documents:
- Your last 4 pay stubs of your current job
- 2023 1040 tax return
- 2023 W-2
- Letter from employer stating date of hire, hourly wage, and average hours per week
Upload document for employment verification. *

Cancelof
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Early Head Start Enrollment Application

Parent/Guardian Information

Parent/Guardian Address

Additional Parent/Guardian

Other Adults

Family Information

Child's Information (Applicant)

Attachments to upload