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Head Start Application
English Head Start Pre-Form
Please complete this form to begin the Head Start application process. All fields marked with an * are required. If you have questions, look at our
FAQ
, or
contact us
.
Child's Name
*
First
Middle
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Child Allergies
*
Child Health Concerns
*
Child Medications
*
Primary Health Coverage
*
Medicaid
Private (through Individual/Employer)
No Insurance
Other
Medicaid Eligibility
*
Not Eligible
On Medicaid
Applied (Potentially)
Insurance/Medicaid #
*
Dental Coverage
*
Dental Coverage #
*
Dentist’s Office Name, Address, Phone #
*
Doctor’s Office Name, Address, Phone #
*
Adult's Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name
This field is for validation purposes and should be left unchanged.