2026-2027 Head Start/ECEAP Application English

Head Start/ECEAP Application 2026-2027
Welcome! Please complete one application packet per child and attach the required documents.

Please note: This application is for the 2026-2027 school year to begin in the Fall of 2026. If you are looking to apply for the CURRENT school year, you can find the 2025-26 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
Gender*

MaleFemale
What is this child's home language?*
2nd language
This child speaks:*

Only EnglishMostly English and another languageSome English, but mostly another languageBoth English and another language the same (bilingual)Only a language other than English
What is this child's race? Check all that apply.*

African/African American/BlackAsianAlaska Native/Native American/American IndianHispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDecline to ReportNot listed above
What is your family's heritage/tribe/country of orgin?
Has this child been previously enrolled in these programs? Only check the most recent.*

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 County, not a PSESD ProgramMigrant/Seasonal Head Start anywhere in Washington StatePrevious preschool enrollment (ages 3-5)No previous preschool enrollment (ages 3-5)None
When did this child last attend?
Name and Location of program:
Is this child currently enrolled in a community slot at this site?*

YesNo
Is this child a sibling of a child currently enrolled in the program you are applying to?*

YesNo
Is this child ever been in foster, kinship or orphanage care?*

YesNo
Is this child in official foster care of kinship care with a grant amount?*

YesNo
If yes, what is the Case Number or Client ID Number?
What is the monthly grant/payment amount?
What is the monthly grant/payment source:

DSHSSSITribeOther
# of children covered by grant amount
Is this child in kinship care without a grant amount*

YesNo
Was this child adopted after foster care or kinship care or from an orphanage from another country?*

YesNo
Was this child recently reunited with their parent(s) after foster or kinship care?*

YesNo
The questions below are for information only. Answering "Yes" will not affect your eligibility or enrollment in the program.
Does your family currently receive services/support through Child Protective Services (CPS), Family Assessment Response (FAR), Indian Child Welfare (ICW), comparable tribal services, or law enforcement/court system?*

YesNo
Has your family received services/support from CPS/FAR/ICW, comparable tribal services, or law enforcement/court system in the past*

YesNo
Is your family currently approved for childcare through CPS or FAR?*

YesNo
If yes, how many approved hours per week?
Has this child ever been asked to leave an early learning program because of behavior issues?*

YesNo
Child Information - Health
Does this child have medical insurance?*

YesNo
If yes, what type?

Washington Apple Health/Provider OnePrivate InsuranceTribalMilitary Medical Coverage
Does this child have a regular doctor or medical clinic?*

YesNo
If yes, name of clinic/provider:
If yes, name of medical professional:
Does this child have dental insurance?*

YesNo
If yes, what type?

Washington Apple Health/Provider OnePrivate InsuranceTribalABCDMilitary Dental Coverage
Does this child have a regular dentist or dental clinic?*

YesNo
If yes, name of clinic/provider:
If yes, name of dental professional:
What is your child's immunization status?*

Fully immunizedExemptNot Fully immunized or exemptNot sure
Does this child have a chronic health condition (may include mental health, asthma, cancer, diabetes, seizures, ADHD, autism, spina bifida, sickle cell disease, or life-threatening allergies)?*

YesNo
If yes, please describe:
If yes, the health condition is considered:

SevereModerateMild
If yes, has a Health Care Provider diagnosed this condition?

YesNo
Child Information - Development
Do you have any concerns about this child's health?*

YesNo
If yes, please check all that apply:

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:
Does this child have a current and active Individual Education Plan (IEP) or Individual Family Service Program (IFSP)*

YesNo
If you checked yes, pleae provide a copy with your application.
If you checked no, please check if any of these apply:

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
This child lives with:*

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 with equally shared time and custody (complete Parent/Guardian 1 & 2)Two parents/guardians in two households, one parent/guardian with primary custody (complete Parent/Guardian 1)
Parent/Guardian 1: Name:*

First NameLast Name
Parent/Guardian 1: Relationship to child:*

Biological/Adopted/StepparentFoster ParentGrandparentAunt/UncleOther
Parent/Guardian 1: Gender

MaleFemale
Parent/Guardian 1: Date of Birth*

MonthDayYear
Date
Parent/Guardian 1: Address (Include City, State, Zip)
Parent/Guardian 1: Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:*

HomeCellWork
Parent/Guardian 1: Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:

HomeCellWork
Parent/Guardian 1: Email
example@example.com
Parent/Guardian 1: Were you under the age of 18 when this child was born?*

YesNoN/A
Parent/Guardian 1: What language(s) do you speak?*
Do you need an English interpreter?*

YesNo
Do you or any members of your family have ADA or other accessibility needs we can support?*

YesNo
Parent/Guardian 1: What is your race? Check all that apply*

African/African American/BlackAsianAlaska Native/Native American/American IndianHispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDeclined to ReportNot Listed Above:
Parent/Guardian 1: What is the highest level of education you completed?*

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
Parent/Guardian 1: Are you currently employed*

YesNoNo, retired or disabledSeasonal
Parent/Guardian 1: If yes, how many hours per week (including travel)
Parent/Guardian 1: Employer Name
Parent/Guardian 1: Are you currently in job training or school?*

YesNo
Parent/Guardian 1: If yes, how many hours per week (including class time, study time, and travel)?
School name:
Parent/Guardian 1: Are you in an approved WorkFirst activity?*

YesNo
Parent/Guardian 1: If yes, describe the activity and the number of approved hours per week:
Parent/Guardian 1: Are you or have you been in the U.S military?*

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
Parent/Guardian 2: Relationship to child:

Biological/Adopted/StepparentFoster ParentGrandparentAunt/UncleOther
Parent/Guardian 2: Gender

MaleFemale
Parent/Guardian 2: Date of Birth

MonthDayYear
Date
Address (Include City, State, Zip)
Parent/Guardian 2: Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:

HomeCellWork
Parent/Guardian 2: Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:

HomeCellWork
Parent/Guardian 2: Email
example@example.com
Parent/Guardian 2: Were you under the age of 18 when this child was born?

YesNoN/A
Parent/Guardian 2: What language(s) do you speak?
Do you need an English interpreter?

YesNo
Do you or any members of your family have ADA or other accessibility needs we can support?*

YesNo
Parent/Guardian 2: What is your race? Check all that apply

African/African American/BlackAsianAlaska Native/Native American/American IndianHispanic/LatinoNative Hawaiian or Pacific IslanderWhiteDecline to ReportNot Listed Above:
Parent/Guardian 2: What is the highest level of education you completed?

6th grade or less7th to 12th grade, no diploma or GEDHigh school diplomaGEDSome college/advanced trainingProfessional certificateAssociate degreeBachelor's degreeMaster's or doctorate degreeNone
Parent/Guardian 2: Are you currently employed

YesNoNo, retired or disabledSeasonal
Parent/Guardian 2: If yes, how many hours per week (including travel)
Parent/Guardian 2: Employer Name
Parent/Guardian 2: Are you currently in job training or school?

YesNo
Parent/Guardian 2: If yes, how many hours per week (including class time, study time, and travel)?
School name & major/goal:
Parent/Guardian 2: Are you in an approved WorkFirst activity?

YesNo
Parent/Guardian 2: If yes, describe the activity and the number of approved hours per week:
Parent/Guardian 2: Are you or have you been in the U.S military?

Yes, current service memberYes, currently deployed or have been in the last 12 months/for a total of 19 monthsYes, veteranNo
Family Concerns
Please check areas of concern that you have for yourself/family in your household.*

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
Household member has a disability or has a chronic physical or mental health condition and is:

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
Does this household receive subsidized housing, such as a housing voucher or cash assistance for housing?*

YesNo
What is your family's current housing situation? The McKinney-Vento Act provides services and supports for children and youth experiencing homelessness. Your answers may help us determine the services your child may be eligible to receive*

OwnRentTemporary Military 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
If you are living in someone else's house or apartment with another family please select one option:

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
Check all that apply if you, this child, or another person living in your home related to you by blood, marriage, or adoption receives Public Assistance.

SSI for disabilityTemporary Assistance for Needy Families (TANF) cashBasic Food (SNAP
Does a parent/guardian in your household pay legally binding child support to another household?

YesNo
If you marked SSI for disability, who is it receives it:

ChildParent/GuardianOther, Relationship to child:
Check all that apply if your family receives the following:*

Child-only TANFWorkFirstWorking Connections Child Care subsidyWICNone
Were you referred to this program by an agency?*

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
Parent/Guardian 1: *

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

MonthDayYear
Date
Parent/Guardian 1 - Are you the applying child's biological or adoptive parent?*

YesNo
Parent/Guardian 1 - If no, are you married to the parent/guardian of the applying child?

YesNo
Parent/Guardian 2:

First NameLast Name
Parent/Guardian 2 - Date of Birth

MonthDayYear
Date
Parent/Guardian 2 - Are you the applying child's biological or adoptive parent?*

YesNo
Parent/Guardian 2 - If no, are you married to the parent/guardian of the applying child?

YesNo
Additional Household Members
1 - Name

First NameLast Name
1 - Birthdate

MonthDayYear
Date
1 - Relationship to child
1 - Is this person financially supported by parent/guardian of child?

YesNo
1 - Is this person related to parent/guardian of child by blood, marriage, or adoption?

YesNo
2 - Name

First NameLast Name
2 - Birthdate

MonthDayYear
Date
2 - Relationship to child
2 - Is this person financially supported by parent/guardian of child?

YesNo
2 - Is this person related to parent/guardian of child by blood, marriage, or adoption?

YesNo
3 - Name

First NameLast Name
3 - Birthdate

MonthDayYear
Date
3 - Relationship to child
3 - Is this person financially supported by parent/guardian of child?

YesNo
3 - Is this person related to parent/guardian of child by blood, marriage, or adoption?

YesNo
4 - Name

First NameLast Name
4 - Birthdate

MonthDayYear
Date
4 - Relationship to child
4 - Is this person financially supported by parent/guardian of child?

YesNo
4 - Is this person related to parent/guardian of child by blood, marriage, or adoption?

YesNo
Do you have additional people to add?

YesNo
5 - Name

First NameLast Name
5 - Birthdate

MonthDayYear
Date
5 - Relationship to child
5 - Is this person financially supported by parent/guardian of child?

YesNo
5 - Is this person related to parent/guardian of child by blood, marriage, or adoption?

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*
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 2026-2027

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

Additional Household Members

Required Documents