Head Start Pre-Application

Head Start Pre-Application

Please call (607) 776-2125 and ask for Head Start if you have any questions.
Parent/Guardian's Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
How would you like us to contact you?*

Phone CallText MessageEmail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you applying as a Prenatal?*

YesNo
Due Date*

MonthDayYear
Date
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Are you looking for Home Based or Center Based programs? Please select both if you do not have a preference.*

Home BasedCenter Based
How did you hear about our program?*

Brochure/FlyerRadioEventFriendReferralDSSWebsiteSchool DistrictHealthy Families
Please list any specific questions you would like answered when we contact you to set up your application visit, or add any additional children that you wish to apply.
Once a pre-application is submitted, a Head Start staff member will reach out to set up an application visit.

*Completing an application does not guarentee an open spot for the applying child. Response time may take up to two weeks once pre-application is received.
Should be Empty: