Head Start/Early Head Start Program Application 2026-2027

  • Head Start/Early Head Start Program Application

    Serving Washington County Residents

  • Child Information

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  • Gender*
  • Who does the child live with?*
  • Who has primary custody of the child?*
  • Is your child/ren receiving services through Northwest Regional Education Service District (NWRESD) and/or have an Individual Family Service Plan (IFSP)?*
  • Are you enrolling another child into the program?*

  • Child 2 Information

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  • Gender*
  • Who does the child live with?*
  • Who has primary custody of the child?*
  • Is your child/ren receiving services through Northwest Regional Education Service District (NWRESD) and/or have an Individual Family Service Plan (IFSP)?*
  • Are you enrolling another child into the program?*

  • Child 3 Information

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  • Gender*
  • Who does the child live with?*
  • Who has primary custody of the child?*
  • Is your child/ren receiving services through Northwest Regional Education Service District (NWRESD) and/or have an Individual Family Service Plan (IFSP)?*
  • Is there a parent/guardian pregnant?*
  • Are you interested in applying for prenatal services? (proof of pregnancy is required)*

  • Parent(s)/Guardian(s) Information

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  • Gender*
  • English Proficiency*
  • Do you need an interpreter?*
  • Email opt-in?*
  • Format: (000) 000-0000.
  • Text opt-in?*
  • Is the parent/guardian currently employed or unemployed?*
  • Has the parent/guardian been paid in cash in the last 12 months? (**If no, please submit W2, tax return, unemployment benefits, child support award)*
  • Do you have an additional address for mailing or for pick up/drop off?*

  • Additional Parent/Guardian Information

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  • Gender
  • Does the parent/guardian live with the family?*
  • Is the parent/guardian currently employed or unemployed?*
  • Has the parent/guardian been paid in cash in the last 12 months? (**If no, please submit W2, tax return, unemployment benefits, child support award)*
  • English Proficiency
  • Do you need an interpreter?
  • Email opt-in?
  • Format: (000) 000-0000.
  • Text opt-in?
  • Is your living address the same as family's?

  • Eligibility Information

    Answer the following questions as completely as possible. This will help us determine your eligibility.
  • Check all that apply (**please submit a TANF award letter, or SNAP award letter, or SSI award letter):*
  • Current housing situation:*
  • Additional Child/Family Information (check all that apply)*

  • List additional children/dependents living in the home (non-applicant)

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  • Financially supported by the parent(s)/guardian(s)
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  • Financially supported by the parent(s)/guardian(s)
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  • Financially supported by the parent(s)/guardian(s)
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  • Financially supported by the parent(s)/guardian(s)
  • How did you hear about Community Action Head Start and Early Head Start?*

  • Upload Eligibility Information

    The application cannot be processed if the required eligibility documents are missing
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  • I affirm that to the best of my knowledge, all the information that I have provided is complete and correct. I understand that if I deliberately misrepresent my family circumstances, my family may not be eligible for services. By signing this application, I authorize Community Action Head Start to release this information to Early Learning Washington County, Beaverton School District, Hillsboro School District, Tigard/Tualatin School District, Sherwood School District, Oregon Child Development Coalition, NWRESD, LifeWorks Northwest, Other Head Start programs, DHS and programs within Community Action Organization for enrollment purposes.

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  • Declaration of Income/No Income

    This must be completed if you are paid in cash or cannot provide proof of your income
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  • Are you enrolling another child into the program?*
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  • Are you enrolling another child into the program?*
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  • Please complete the questions below:

  • Declaration of Income without Proof of Documentation

    This is to be completed if you are paid in cash or cannot provide proof of your income.
  • Did you receive income in the last 12 months?*

  • Declaration of NO Income

    If no to having income in the last 12 months, how have you paid for the following costs:
  • Did you receive income in the last 12 months?*

  • Declaration of Income without Proof of Documentation

    This is to be completed if the additional parent/guardian was paid in cash or cannot provide proof of your income.
  • Did you receive income in the last 12 months?*

  • Declaration of NO Income

    If no to having income in the last 12 months, how have you paid for the following costs:
  • Did you receive income in the last 12 months?*

  • Declaration of NO Income

    If the additional parent said no to having income in the last 12 months, how have you paid for the following costs:
  • Did you receive income in the last 12 months?*

  • I certify that all the above information is true and correct. I understand that this information will be used to determine my eligibility for the Community Action Head Start program. I understand that if I provide false information, my participation in the program may be denied or terminated.

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