R9 Head Start/EHS Application

Region 9 Head Start/Pre-K & Early Head Start Application

****IMPORTANT*** There is a section where you can upload your documents (12 months income, Birth Certificate, Medicaid/Health Insurance Card, Immunization Records, and Current Physical and Dental) if you choose to upload them with the application. If not, you will need to submit your documents to sylvia.wilson@regionix.org (for Head Start/PreK) or dana.jensen@regionix.org (for EHS). Or, you can bring them into one of our sites and we an make copies. Thank you!
Today's Date*

MonthDayYear
Date
Choose the site you are applying for*

Secondary or Other Adult
**If there is not a secondary or other adult in the home please proceed the next page "Additional Child (non-applicant)"**
Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Race
Hispanic

YesNo
English Proficiency
Other Language (if applicable)
Other Language Proficiency (if applicable)
Highest Grade Completed
Employment Status
Relationship to Child
Custody of the Child

YesNo
Check All That Apply

Lives with FamilyProvides Financial SupportTeen Parent
E-mail Address
example@example.com
Phone

Additional Child (Non-Applicant)
**If there aren't additional children living in the home please proceed to the page "Family Information"**
Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Race
Hispanic

YesNo
English Proficiency
Other Language (if applicable)
Other Language Proficiency (if applicable)

Additional Child (Non-Applicant)
**If there aren't additional children living in the home please proceed to the next page to "Family Information"**
Name

First NameMiddle InitialLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Race
Hispanic

YesNo
English Proficiency
Other Language (if applicable)
Other Language Proficiency (if applicable)
Are there any more children living in the home?

YesNo
If you selected 'yes' to more children living in the home, how many?

Income & Documents
Please upload documents if possible. You can take photos of your documents or upload them directly from your device in various formats like Word, PNG, JPEG, or PDF. It is not required to upload documents, however, we will contact you for these documents once we receive the application.
12 Months Income Documentation (pay stubs, tax forms, employer letter, etc. to show 12 months of income. Or you can upload your SNAP benefits letter if you receive SNAP).

Cancelof
Birth Certificate

Cancelof
Immunization Records

Cancelof
Medicaid Card and Current Physical/Dental Exams

Cancelof
Certification: I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.
Signature*

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Region 9 Head Start/Pre-K & Early Head Start Application