2025 - 2026 CSO Head Start / Early Head Start Application

  • CSO

    COMMUNITY SERVICES OFFICE

  • Mailing Address: P.O. Box 1175, Hot Springs, AR 71902
    Office Phone: 501-624-5724 Fax: 501-624-1645
    Email: headstartdirector@csoarkansas.org

  • 2025 - 2026 Application

  • Head Start / Early Head Start /Early Head Start Child Care Partnerships

  • Mission Statement

  • The Community Services Office, in partnership with the community, will focus on strengthening the educational, social, and economic well-being of individuals and families as they move toward economic independence and self-sufficiency.
  • If you need any assistance completing this application, please contact us.
    We will gladly help you.
  • ***AN INCOMPLETE APPLICATION MAY DELAY YOUR CHILD'S ENROLLMENT***
  • 2025-2026 CSO HS/EHS/EHSCCP Application Revised: 8/12/22

  • Enrollment Process

  • The enrollment process of your child is not complete without all the information listed below:

  • This Institution is an Equal Opportunity Provider

    To File a program discrimination complaint, complete the USDA program Discrimination Complaint Form, Ad-3027, found online at http://www.ascr.usda.gov/complaint filing cust.html and at any USDA office or
    write a letter addressed to USDA and provide in the letter all the information
    requested in the form.

    To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; Fax:(833) 256-1665 | (202) 690-7442; or Email: program.intake@usda.gov

  • 2025-2026 CSO HS/EHS/EHSCCP Application Revised: 8/12/22
  • CS

  • Eligibility

    Children from birth to 5 are eligible for Head Start or Early Head Start. There is no cost to attend the Head Start/Early Head Start Program; however, transportation is not provided. The following are categorically eligible:
    • Children with family incomes below the Federal Poverty Level
    • Children of families eligible for Temporary Assistance for Needy Families (TANF)
    • Children of families eligible for Supplemental Security Income (SSI)
    • Children who are experiencing Homelessness
    • Children in the Child Welfare System (Foster Care)

  • Recruitment

    Head Start/Early Head Start families are recruited in the County. Advertisements and applications are made available at various locations and can also be obtained by contacting CSO. When parents or guardians wish to enroll their children, they complete an application.

  • Selection

    Upon receipt of an application, it is first checked for completion. If it is complete, the ERSEA Coordinator screens the application for eligibility using a point system, which is based on the needs of the family. After review, all eligible applicants are either enrolled or placed on a waiting list and their parent/guardian is notified by letter or phone concerning the status of their application.

  • Enrollment

    Applicants are placed on the waiting list in order of need and are enrolled when a slot becomes available. Upon enrollment, an appointment time is set for the family to complete the Orientation. During Orientation, they complete more paper work and speak to the content staff. Early Head Start students must requalify to attend Head Start.

  • Attendance

    Head Start children are expected to come to class on the first day of school or upon enrollment and Early Head Start children upon enrollment.

  • Criteria for Selection

    • ➤ Head Start/Early Head Start will place families that are at or under the income guideline (100% or below) as soon as slots become available using a point system by which the families with the most points are placed first.
    • ➤ Eligible families that are between 100% and 130% on the income guideline will be placed second (35% of slots may be in this category)
    • ➤ If slots are still available, eligible families who are over 130% will be added last (10% of slots may be in this category)
    • ➤ In the event that several families have the same number of points, the family who applied first will be placed first.
    • ➤ At least 10% of our slots will be used for children with disabilities.
  • Note: In order for you to receive notification, it is important that we maintain a current address and phone number for your family. Therefore, please notify us if any changes are made.
  • 2025-2026 CSO HS/EHS/EHSCCP Application Revised: 8/12/22
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  • Child's Personal Data

  • Date Applied
     - -

  • Child's Information:

  • Date of birth:
     - -
  • Language(s) spoken:
  • Gender:
  • Race: (Circle one or any that apply to you)
  • Type a question
  • Did Head Start/ Early Head Start assist you in filling out an application for AR Kids Insurance?

  • Signature:

  • Please read & sign: I, (Legal Guardian) do hereby give my consent to the Director of Community Services Office Head Start/Early Head Start, or his/her duly appointed representative, for said child, to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of an emergency when the parent/guardian cannot be reached. Consent is also given for the Director or his duly appointed representative to transport said child for emergency medical treatment if the parent cannot be reached. I, the parent/guardian of this child, understand that I may ask for a conference with the caregiver(s) as needed.

  • Date
     - -

  • First Parent/Guardian's Information:

  • Which one are you?
  • Check one:
  • Incarcerated:
  • In Drug or Alcohol Rehab:
  • Is child living with relatives/friends due to parent incarceration or abandonment?
  • Is mother living with enrolling child's father?
  • Who is legally responsible for child?
  • Foster Care
  • In Military Services
  • Is parent currently deployed
  • DOB
     - -

  • Work Hours

  • Employed full time?
  • Part time?
  • Retired?
  • Veteran?
  • Disabled?
  • Did you graduate?
  • Date graduated
     - -
  • GED?
  • Move in date
     - -
  • Is your current address a temporary living arrangement?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Parent in School/Training:
  • Student Status:
  • Do you have a Degree or Certificate?
  • Are you pregnant?
  • Expected Due Date:
     - -

  • Second Parent/Guardian's Information:

  • Which one are you? Parent
  • Check one:
  • Incarcerated:
  • In Drug or Alcohol Rehab:
  • Is child living with relatives/friends due to parent incarceration or abandonment?
  • Is mother living with enrolling child's father?
  • Who is legally responsible for child?
  • In Military Services
  • Is parent currently deployed
  • DOB
     - -

  • Work Hours:

  • Employed full time?
  • Part time?
  • Retired?
  • Veteran?
  • Disabled?
  • Did you graduate?
  • Date graduated
     - -
  • GED?
  • Is your current address a temporary living arrangement?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Parent in School/Training:
  • Student Status:
  • Do you have a Degree or Certificate?
  • Are you pregnant?
  • Expected Due Date:
     - -
  • 2025-2026 CSO HS/EHS/EHSCCP Application Revised: 8/12/22

  • Family Assistance Information:

  • How did you find out about the Head Start/Early Head Start Program? (Circle all that apply)
  • Do you receive assistance? Yes (Check all received below.)
  • Do you receive Voucher Subsidies for Childcare?
  • Do you receive any of the following? (Please supply documentation if for parent or enrolling child.)
  • Is it for the child you are enrolling?
  • (If yes, please supply documentation.)
  • Were you unemployed last year?
  • Did you receive Unemployment pay?
  • (If yes, please supply documentation.)

  • Do you receive any of the below services from Community Services Office:

  • Emergency Assistance Program
  • Emergency Medical Prescription
  • Employment Assistance
  • Food Pantry
  • Low Income Home Energy Assistance Program (LIHEAP)
  • Rental Assistance
  • Transportation (Elderly / Disabled)
  • Utility Assistance (Other than LIHEAP)
  • Quarterly Commodities Distribution

  • Physical Examination:

  • A physical examination by a physician is required. This exam must include age-appropriate Lead and Hemoglobin/ Hematocrit (blood work) tests. A TB assessment may be conducted if this child is considered to be at risk. If you do not have a copy of a current physical exam for your child, you will be asked to take your child to the doctor to obtain one. This should be completed before your child is enrolled.
  • Is a copy of child's physical exam included with this application?
  • Format: (000) 000-0000.
  • Date of child's last physical examination:
     - -

  • Immunization:

  • Before your child can be enrolled into Head Start/Early Head Start, we must be provided an authorized record of up-to-date immunizations or documentation of a religious or medical exemption from the Arkansas Dept. of Health and Human services.
  • Child's shot record verified by:

  • Disability / Disease History

  • Please check any your child currently has or has had in the past
  • Has your child been diagnosed by a professional for the items circled above?
  • Does your child have an Individualized Education Plan (IEP or IFSP)?
  • Is your child currently receiving services from another agency?
  • Does your child have food allergies?
  • 2025-2026 CSO HS/EHS/EHSCCP Application Revised: 8/12/22
  • 8

  • Medical Information:

  • Dental Examination:

  • An age-appropriate dental exam by a dentist is required. If you do not have a copy of a current exam for your child, you will be asked to take your child to the dentist to obtain one. This should be completed before your child is enrolled.
  • Is a copy of child's dental exam included with this application?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of child's last dental exam:
     - -

  • Birth Information:

  • Was child premature?
  • Expected Due Date
     - -
  • While in the hospital, did the child experience any complications?

  • Social/Emotional Development:

  • Child's special food needs:
  • Special Concerns:
  • Requires help:
  • Does your child have trouble with any of the following? (Check any that apply to your child.)
  • Is your child receiving mental health services?
  • Do you have any other concerns about your child or his/her behaviors?
  • 2025-2026 CSO HS/EHS/EHSCCP Application Revised: 8/12/22
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  • Living Situation:

  • Do you plan to relocate from this county?
  • Rows
  • Type of housing:
  • Do you consider yourself homeless/Moving place to place?
  • If yes, where are you sleeping? (Check one)
  • Do you live with someone?
  • Is someone living with you?
  • Rows

  • Authorization for Release of Records

  • To Whom It May Concern:
    I do hereby give my permission for:

  • to release the following contained in their files concerning my child's to:
    Community Services Office, Head Start/Early Head Start
    Attention: ERSEA Director
    P.O. Box 1175, Hot Springs, AR 71902
    Office: 501-624-5724 Fax: 501-624-1645
    I authorize the release of any medical information necessary to meet this request. Such release may include information concerning communicable or venereal diseases including, but not limited to diseases such as hepatitis, syphilis, gonorrhea, and human immunodeficiency virus, aka Acquired Immune Deficiency Syndrome (AIDS).
  • Date
     - -
  • Date
     - -

  • Identifying Information:

  • DOB
     - -
  • Most recent Physical Examination Date:
     - -
  • Most recent Dental Examination Date:
     - -
  • Most recent Diagnostic Evaluation Date:
     - -
  • Information Needed:
  • 2025-2026 CSO HS/EHS/EHSCCP Application Revised: 8/12/22
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  • Should be Empty: