Conditional Format 2025-26 Head Start & Early Head Start Application

Parent/Guardian (Adult 1)*

First NameLast Name
Relationship to Child (Adult 1)*
Primary Adult (Adult 1)*

YesNo
Birth Date (Adult 1)*

MonthDayYear
Living Address (Adult 1)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your family experiencing Homelessness? (Adult 1)*
My family lacks a fixed, regular, and adequate nighttime residence or my family shares housing with others due to loss of housing or economic hardship or homeless services provider letters.
Email (Adult 1)*
example@example.com
Primary Phone Type (Adult 1)*
Primary Phone Number (Adult 1)*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have more than one phone?*

YesNo
Secondary Phone Type (Adult 1)
Secondary Phone Number (Adult 1)
Please enter a valid phone number.Format: (000) 000-0000.
Teen Parent (19 or younger) (Adult 1)*
Custody of Child (Adult 1)*
Lives with Child*
Child's Relationship to Adult (Adult 1)*
English Level (Adult 1)*
Level of Education
Employment Status (Adult 1)*
* IF UNEMPLOYED PLEASE FILL OUT THE ZERO INCOME DECLERATION*(See after submitting application)
Are you the only person responsible for the child(ren)you are applying for?*

YesNo

Parent/Guardian (Adult 2)

First NameLast Name
Relationship to Child (Adult 2)
Primary Adult (Adult 2)*

YesNo
Birth Date (Adult 2)*

MonthDayYear
Living Address (Adult 2)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your family experiencing Homelessness? (Adult 2)*
My family lacks a fixed, regular, and adequate nighttime residence or my family shares housing with others due to loss of housing or economic hardship or homeless services provider letters.
Email (Adult 2)
example@example.com
Primary Phone Type (Adult 2)*
Primary Phone Number (Adult 2)*
Please enter a valid phone number.Format: (000) 000-0000.
Do you have more than one phone? (Adult 2)*

YesNo
Secondary Phone Type (Adult 2)
Secondary Phone Number (Adult 2)
Please enter a valid phone number.Format: (000) 000-0000.
Teen Parent (19 or younger) (Adult 2)*
Custody of Child (Adult 2)*
Lives with Child (Adult 2)*
Child's Relationship to Adult (Adult 2)*
English Level (Adult 2)*
Employment Status (Adult 2)*
* IF UNEMPLOYED PLEASE FILL OUT THE ZERO INCOME DECLERATION*(See after submitting application)
Level of Education
Total # of people who live in the child's household and are a part of his/her family*
List Additional Members of Family/Household (Other than members already on application, Save and Add Row between members*)

Documentation (Child 1)

Please upload a copy of the following documents. Not all documents are required. Image files are accepted. You can simply take a picture of the document with your phone and upload it here.
Parent's Driver License*

Cancelof
Child's Birth Certificate*

Cancelof
Proof of Pregnancy from Doctor

Cancelof
Medical Insurance Card (Medicaid, All Kids, etc.)*

Cancelof
Proof of Family's Income. (income tax form 1040, W-2 form, current pay stub or written statement from your employer.)

*IF UNEMPLOYED PLEASE FILL OUT THE ZERO INCOME DECLERATION* (See after submitting application)
Cancelof
Current status of TANF, SSI, or Foster Care Documentation

Cancelof
Proof of Disability Services

Cancelof
WIC card

Cancelof
Current Food Stamp Assistant Letter or Card (SNAP)

Cancelof
Child Care South (Subsidy) award letter

Cancelof
Proof of School Schedule (If currently in School) *(Online classes excluded)

Cancelof
Today's Date

MonthDayYear
Date

Documentation (Child 2)

Please upload a copy of the following documents. Not all documents are required. Image files are accepted. You can simply take a picture of the document with your phone and upload it here.
Child's Birth Certificate*

Cancelof
Proof of Pregnancy from Doctor

Cancelof
Medical Insurance Card (Medicaid, All Kids, etc.)*

Cancelof
Proof of Family's Income. (income tax form 1040, W-2 form, current pay stub or written statement from your employer.)

*IF UNEMPLOYED PLEASE FILL OUT THE ZERO INCOME DECLERATION* (See after submitting application)
Cancelof
Current status of TANF, SSI, or Foster Care Documentation

Cancelof
Proof of Disability Services

Cancelof
WIC card

Cancelof
Current Food Stamp Assistant Letter or Card (SNAP)

Cancelof
Child Care South (Subsidy) award letter

Cancelof
Proof of School Schedule (If currently in School) *(Online classes excluded)

Cancelof
Today's Date

MonthDayYear
Date

Documentation (Child 3)

Please upload a copy of the following documents. Not all documents are required. Image files are accepted. You can simply take a picture of the document with your phone and upload it here.
Child's Birth Certificate*

Cancelof
Proof of Pregnancy from Doctor

Cancelof
Medical Insurance Card (Medicaid, All Kids, etc.)*

Cancelof
Proof of Family's Income. (income tax form 1040, W-2 form, current pay stub or written statement from your employer.)

*IF UNEMPLOYED PLEASE FILL OUT THE ZERO INCOME DECLERATION* (See after submitting application)
Cancelof
Current status of TANF, SSI, or Foster Care Documentation

Cancelof
Proof of Disability Services

Cancelof
WIC card

Cancelof
Current Food Stamp Assistant Letter or Card (SNAP)

Cancelof
Proof of School Schedule (If currently in School) *(Online classes excluded)

Cancelof
Today's Date

MonthDayYear
Date

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2025-26 Head Start & Early Head Start Application