R9 Head Start/EHS Application - English

  • 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 calla.goeller@regionix.org (for Head Start/PreK) or susana.guthrie@regionix.org (for EHS). Or, you can bring them into one of our sites and we an make copies. Thank you!
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  • Applicant Information (Child)

  • Gender*
  • Hispanic*
  • Medicaid Eligibility*

  • Is this Applicant Considered "At-Risk - Biological/Medical"? Please See Definition Below:

    At-Risk - Biological/Medical: A diagnosed medical condition that may produce developmental delay in some children such as prematurity, low birth weight, birth trauma, prenatal exposure to alcohol or drugs, diagnosed genetic or neurological disorder, hearing loss, physical impairment, growth problems, or diagnosed mental/psychosocial disorder.

  • Is this child at-risk for biological or medical reasons based on the definition above?*

  • Is this Applicant Considered "At-Risk - Environmental"? Please See Definition Below:

    At-Risk - Environmental: Environments that pose a substantial threat to development, including chronic abuse of drugs or alcohol, child abuse, domestic violence, developmental or psychiatric disability in a caregiver, etc. 

  • Is this child at-risk for environmental reasons based on the definition above?*

  • Primary Adult

  • Gender*
  • Hispanic*
  • Custody of the Child*
  • Check All That Apply*
  • Format: (000) 000-0000.

  • 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)"**

  • Gender
  • Hispanic
  • Custody of the Child
  • Check All That Apply
  • Format: (000) 000-0000.

  • Additional Child (Non-Applicant)

  • **If there aren't additional children living in the home please proceed to the page "Family Information"**

  • Gender
  • Hispanic

  • Additional Child (Non-Applicant)

  • **If there aren't additional children living in the home please proceed to the next page to "Family Information"**

  • Gender
  • Hispanic
  • Are there any more children living in the home?

  • Family Information

  •  - -
  • Is your mailing address the same as your living address?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do You Opt in for Text Messages?*
  • Household Parental Status*
  • Is your household learning or have acquired another language in addition to English (including the children)?*
  • Are you Homeless?*
  • Are you Active Duty Military?*
  • Are you a Military Veteran?*
  • Do you receive SNAP (food stamps) benefits?*
  • Do you receive WIC benefits?*
  • Were you Referred by CYFD or other Child Welfare Agency?*

  • 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. 

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  • 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. 

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