Head Start/Early Head Start Program Application 2025-2026

Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Who does the child live with?*

Who has primary custody of the child?*

Are you enrolling another child into the program?*

YesNo

Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Who does the child live with?*

Who has primary custody of the child?*

Are you enrolling another child into the program?*

YesNo

Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Who does the child live with?*

Who has primary custody of the child?*

Is there a parent/guardian pregnant?*

YesNo

Are you interested in applying for prenatal services? (proof of pregnancy is required)*

YesNo

Due Date*

Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemale

Primary language at home*

English Proficiency*

NoneLittleModerateProficient

Do you need an interpreter?*

YesNo

Email Address

example@example.com

Email opt-in?*

YesNo

Phone Number*

Please enter a valid phone number.

Text opt-in?*

YesNo

Is the parent/guardian currently employed or unemployed?*

EmployedUnemployed

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)*

YesNo

Living Address*

Street Address and Apartment #

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have an additional address for mailing or for pick up/drop off?*

MailingPick Up/Drop OffNone

Additional Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name

First NameLast Name

Date of Birth

Date

Gender

MaleFemale

Does the parent/guardian live with the family?*

YesNo

Is the parent/guardian currently employed or unemployed?*

EmployedUnemployed

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)*

YesNo

Primary language at home

English Proficiency

NoneLittleModerateProficient

Do you need an interpreter?

YesNo

Email Address

example@example.com

Email opt-in?

YesNo

Phone Number

Please enter a valid phone number.

Text opt-in?

YesNo

Is your living address the same as family's?

YesNo

Living Address

Street Address and Apartment #

Street Address Line 2

CityState / Province

Postal / Zip Code

Check all that apply (**please submit a TANF award letter, or SNAP award letter, or SSI award letter):*

Receiving SNAP (food stamps)Receiving TANF (cash assistance)Receiving Supplemental Security Income (SSI)None

Current housing situation:*

Own/RentSharing a home with family or friends due to economic hardshipLiving in a motel/hotel, trailer park, or campgroundIn a shelter (family/domestic violence-safe house/transitional shelter)Primary nighttime residence not ordinarily used as a regular sleeping accommodation (e.g. park benches)In a car, park, public space, abandoned building, substandard housing, or bus/train station

Is your child/ren receiving services through Northwest Regional Education Service District (NWRESD) and/or have an Individual Family Service Plan (IFSP)?*

YesNo

Name of the Child/ren*

Are you receiving services through Lifeworks Northwest?*

YesNo

Name of the Child/ren*

Are you receiving services through other agencies?*

YesNo

Name of the Child/ren*

Additional Child/Family Information (check all that apply)*

How many people are in your family?*

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

Name

First NameLast Name

Date of Birth

Date

Gender

Relationship to the applicant

Financially supported by the parent(s)/guardian(s)

YesNo

Name

First NameLast Name

Date of Birth

Date

Gender

Relationship to the applicant

Financially supported by the parent(s)/guardian(s)

YesNo

Name

First NameLast Name

Date of Birth

Date

Gender

Relationship to the applicant

Financially supported by the parent(s)/guardian(s)

YesNo

Name

First NameLast Name

Date of Birth

Date

Gender

Relationship to the applicant

Financially supported by the parent(s)/guardian(s)

YesNo

How did you hear about Community Action Head Start and Early Head Start?*

Other (specify)*

Birth Record

Example: Birth certificates, hospital certificates, immunizations, or passport

Income Documentation

Example: W2, tax return, TANF/SNAP award letter, SSI award letter, child support

Foster Placement Letter

Guardianship Letter

Proof of Pregnancy (applies when you are applying for prenatal services)

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.

Parent/Guardian Signature: *

Date*

Date

Head Start/Early Head Start Program Application

Child Information

Child 2 Information

Child 3 Information

Parent/Guardian Information

Additional Parent/Guardian Information

Eligibility Information

Upload Eligibility Information

Declaration of Income/No Income

Declaration of Income without Proof of Documentation

Declaration of Income without Proof of Documentation

Declaration of NO Income

Declaration of NO Income