2025-2026 Head Start/ECEAP Application English

Head Start/ECEAP Application 2025-2026
Welcome! Please complete one application packet per child and attach the required documents.

Please note: This application is for the 2025-2026 school year to begin in the Fall of 2025. If you are looking to apply for the CURRENT school year, you can find the 2024-25 application on the Edwin Pratt ELC homepage.

Eligibility to our programs is determined by child’s age and family income, not by the date you applied.

Our programs fill up fast, so please apply as soon as you can!

The information on your application is confidential and used only to determine your child’s eligibility for our Early Learning Programs.

We do not require, check, or report on immigration or DSHS status.

Please allow yourself plenty of time to complete the application. You will be asked to upload the following required documents at the end. Please have them ready.

If you have any difficulties locating or obtaining any of the requested documents, please call our main office and ask to speak with a family advocate at (206) 393-4350. You can still complete and submit the application, however your child's application will be considered for enrollment only after all documents are received and approved.
Child Information - General
Name*

First NameMiddle InitialLast Name
Preferred Name
Date of Birth (month/day/year)*

MonthDayYear
Date
MaleFemale
What is this child's home language?*
2nd language
Only EnglishMostly English and another languageSome English, but mostly another languageBoth English and another language the same (bilingual)Only a language other than English
African/African American/BlackAsianAlaska Native/Native American/American IndianHispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDecline to ReportNot listed above
Early Support for Infants and Toddlers (ESIT), IDEA Part C, ECLIPSEHead Start/Early Head Start/ECEAP/Early ECEAP in King or Pierce County, Washington State or a PSESD ProgramHead Start/Early Head Start/ECEAP/Early ECEAP in another Washington State CountyMigrant/Seasonal Head Start anywhere in Washington StatePrevious preschool enrollment (ages 3-5)No previous preschool enrollment (ages 3-5)
When did this child last attend?
Name and Location of program:
YesNo
YesNo
YesNo
If yes, what is the Case Number or Client ID Number?
What is the monthly grant/payment amount?
DSHSSSITribeOther
# of children covered by grant amount
YesNo
YesNo
YesNo
The questions below are for information only. Answering "Yes" will not affect your eligibility or enrollment in the program.
YesNo
YesNo
YesNo
If yes, how many approved hours per week?
YesNo
Child Information - Health
YesNo
Washington Apple Health/Provider OnePrivate InsuranceTribalMilitary Medical Coverage
YesNo
If yes, name of clinic/provider:
If yes, name of medical professional:
YesNo
If yes, date of last exam:

MonthDayYear
Date
Date unknown
YesNo
Washington Apple Health/Provider OnePrivate InsuranceTribalABCDMilitary Medical Coverage
YesNo
If yes, name of clinic/provider:
If yes, name of dental professional:
YesNo
If yes, date of last exam:

MonthDayYear
Date
Date unknown
Fully immunizedExemptNot Fully immunized or exemptNot sure
YesNo
If yes, please describe:
SevereModerateMild
YesNo
Child Information - Development
YesNo
Low birth weight (less than 5.5lbs/5lbs 8oz)Preterm birth less than 37 weeksDrug/alcohol affectedHearingFine motor/gross motorTooth pain/decay/bleeding gumsVisionFood Intolerance/special diet
If you chose: Food Intolerance/special diet, please describe:
YesNo
If you checked yes, pleae provide a copy with your application.
My child had an evaluation and was determined eligible for an IEP, but we are waiting for IEP to be issued or declined servicesMy child has had an IFSP in teh past but did not transition to an IEP with the school districtMy child has a diagnosed developmental delay or disability with no IEP, or is being referred for evaluationMy child has a suspected developmental delay or disability.I have concerns about my chilld's develeopmentNone apply
Parent/Guardian Information
One parent/guardian (complete Parent/Guardian 1)Two parents/guardians in the same household (complete Parent/Guardian 1 & 2)Two parents/guardians in two households (complete Parent/Guardian 1 & 2)
Parent/Guardian 1: Name:*

First NameLast Name
Biological/Adopted/StepparentFoster ParentGrandparentAunt/UncleOther
MaleFemale
Parent/Guardian 1: Preferred Pronouns (optional)
Parent/Guardian 1: Date of Birth*

MonthDayYear
Date
Parent/Guardian 1: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1: Phone*
Please enter a valid phone number.
HomeCellWork
Parent/Guardian 1: Alternate Phone
Please enter a valid phone number.
HomeCellWork
Parent/Guardian 1: Email
example@example.com
YesNoN/A
Parent/Guardian 1: What language(s) do you speak?*
YesNo
YesNo
African/African American/BlackAsianAlaska Native/Native American/American IndianHispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDeclined to ReportOther
6th grade or less7th to 12th grade, no diploma or GEDHigh school diplomaGEDSome college/advanced trainingCollege/professional certificateAssociate degreeBachelor's degreeMaster's or doctorate degreeNone
YesNoNo, retired or disabledSeasonal
Parent/Guardian 1: If yes, how many hours per week (including travel)
Parent/Guardian 1: Employer Name
Parent/Guardian 1: Employer Phone Number
Please enter a valid phone number.
YesNo
Parent/Guardian 1: If yes, how many hours per week (including class time, study time, and travel)?
School name & major/goal:
YesNo
Parent/Guardian 1: If yes, describe the activity and the number of approved hours per week:
Yes, current service memberYes, currently deployed or have been in the last 12 months/for a total of 19 monthsYes, veteranNo
Parent/Guardian 2: Name:

First NameLast Name
Biological/Adopted/StepparentFoster ParentGrandparentAunt/UncleOther
MaleFemale
Parent/Guardian 2: Date of Birth

MonthDayYear
Date
Parent/Guardian 2: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2: Phone
Please enter a valid phone number.
HomeCellWork
Parent/Guardian 2: Alternate Phone
Please enter a valid phone number.
HomeCellWork
Parent/Guardian 2: Email
example@example.com
YesNoN/A
Parent/Guardian 2: What language(s) do you speak?
YesNo
YesNo
African/African American/BlackAsianAlaska Native/Native American/American IndianHispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDecline to ReportOther
6th grade or less7th to 12th grade, no diploma or GEDHigh school diplomaGEDSome college/advanced trainingCollege/professional certificateAssociate degreeBachelor's degreeMaster's or doctorate degreeNone
YesNoNo, retired or disabledSeasonal
Parent/Guardian 2: If yes, how many hours per week (including travel)
Parent/Guardian 2: Employer Name
Parent/Guardian 2: Employer Phone Number
Please enter a valid phone number.
YesNo
Parent/Guardian 2: If yes, how many hours per week (including class time, study time, and travel)?
School name & major/goal:
YesNo
Parent/Guardian 2: If yes, describe the activity and the number of approved hours per week:
Yes, current service memberYes, currently deployed or have been in the last 12 months/for a total of 19 monthsYes, veteranNo
Family Concerns
Household member has a disability or has a chronic physical or mental health condition.Child's parent/guardian has learning difficulties, no disabilityHousehold domestic violence (past or current), including in uteroHousehold drug/alcohol issues or substance abuse (past or current), including in uteroFamily is socially isolated, with complete or near-complete lack of contact with othersChild's parent/guardian concern for getting or keeping a jobFamily has legal concernsChild has a family member who attended Indian Boarding SchoolChild's parent/guardian is a migrant or seasonal worker with more than half of family income coming from agricultural workParent and child moved to engage in tradition cultural practices of employment (seasonal or temporary in agricultural or fishing)Child's parent/guardian is/has been incarceratedLoss of parent (death, abandonment)Child's parents/guardians divorced or separated during child's lifeFamily previously homeless (in last 12 months)Family concerns with housingNone
Unable to engage in work/school/family lifeSomewhat able to engage in work/school/family lifeMostly able to engage in work/school/family life
Family Living Situation
YesNo
OwnRentMilitary - waiting for permanent housingIn someone else's house or apartment with another familyIn a motelIn a shelterA car, park, campsite or similar locationTransitional housingMoving from place to place/couch surfingIn a residence with inadequate facilities (no water, heat, electricity)Other
By choice (e.g. to share responsibility, to be close to family, etc.)Due to loss of housing, economic hardship, or similar reason
Family Income and Family Size
SSI for disabilityTemporary Assistance for Needy Families (TANF) cashSNAP
YesNo
ChildParent/GuardianOther, Relationship to child:
Child-only TANFWorkFirstWorking Connections Child Care subsidyWICNone
NoYes
If yes, please name:
How did you find out about this program?*
Please list all people living in this child's primary household.
Applying Child:*

First NameLast Name
Applying Child - Date of Birth*

MonthDayYear
Date
YesNo
YesNo
Parent/Guardian 1: *

First NameLast Name
Parent/Guardian 1 - Date of Birth*

MonthDayYear
Date
YesNo
YesNo
Parent/Guardian 2:

First NameLast Name
Parent/Guardian 2 - Date of Birth

MonthDayYear
Date
YesNo
YesNo
1 - Name

First NameLast Name
1 - Birthdate

MonthDayYear
Date
1 - Relationship to child
YesNo
YesNo
2 - Name

First NameLast Name
2 - Birthdate

MonthDayYear
Date
2 - Relationship to child
YesNo
YesNo
3 - Name

First NameLast Name
3 - Birthdate

MonthDayYear
Date
3 - Relationship to child
YesNo
YesNo
4 - Name

First NameLast Name
4 - Birthdate

MonthDayYear
Date
4 - Relationship to child
YesNo
YesNo
YesNo
5 - Name

First NameLast Name
5 - Birthdate

MonthDayYear
Date
5 - Relationship to child
YesNo
YesNo
YesNo
6 - Name

First NameLast Name
6 - Birthdate

MonthDayYear
Date
6 - Relationship to child
YesNo
YesNo
I promise that the information on this form is true and correct. I have authority to enroll this child and will report my income and family size, as required by the Early Learning Programs. If I knowingly provide false information, I understand my family may be unable to continue services. Additionally, if my child is enrolled in ECEAP, I may have to repay the amount spent on my child.

I understand that information from this application is entered in various Early Learning databases operated by the Department of Children, Youth, and Families (DCYF) and Puget Sound Educational Service District (PSESD). DCYF and PSESD are committed to protecting confidential and personal information that could identify a child or family. No information related to immigration status is entered in the databases or shared with state or federal agencies. Information in the databases may be used for the following:
- Research studies to determine if participating in Early Learning helps children later in life.
- To prove Washington State spends some of their own dollars on programs for families, which is required to receive Temporary Assistance for Needy Families dollars from the federal government.
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

Required Documents

Please contact us if you need help to complete the application or if you do not have any of the required documents listed below.
Copy of child's vaccines*

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Proof of Income: Attach a copy of your proof of income. *

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Use any that apply:

• Last year’s Income Tax Return
• Last year’s W-2 Form
• Pay stubs from the last 12 months
• Current SSI/TANF/SNAP benefits letters
• Foster care grant
• Child support recieved for 12 months
• Employer letter stating your total gross income from the last 12 months
Proof of Family Size: Attach a copy of proof of your family size:*

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Use any of these:

• Last year’s Income Tax Return
• Rental or housing document

• Benefits letter (TANF, SSI, SNAP etc.)
• School records
• Court or legal document
Proof of Child's Age: Attach a copy of proof of your child's proof of birthdate *

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Use any of these:

• Birth Certificate
• Passport/Visa
• Adoption Papers
• Foster Care Authorization Letter
• Current Immunization Record

• DOC residential parenting roster
Proof of Legal Guardianship: Attach a copy of proof of legal guardianship*

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Use any of these:

• Birth Certificate
• Passport/Visa
• Adoption Papers
• Foster Care Record
• Written agreement signed and dated by parent and person assuming custodial responsibility
Proof of Residency: Attach proof of your residency. *

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Use any of these:

• Utility bill
• Lease agreement
• Mortgage Statement
• Property Tax Statement
Other Documents (see below for examples)

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• Current IEP
• Most Recent Well Child Exam
• Most recent dental exam
• Proof of Tribal Membership
Should be Empty:

Head Start/ECEAP Application 2025-2026

Child Information - General

The questions below are for information only. Answering "Yes" will not affect your eligibility or enrollment in the program.

Child Information - Health

Child Information - Development

Parent/Guardian Information

Family Concerns

Family Living Situation

Family Income and Family Size

Required Documents