Headstart Online Application

Parent/Guardian Information












SingleMarriedDivorcedSeparatedWidowed


YesNo
YesNo
YesNo
YesNo
YesNo

YesNo


Children Information

Name DOB Sex Relationship to child Medicad In School? Where?
MF YN
MF YN
MF YN
MF YN
MF YN

Adults in Household

Name DOB Employer



Income Information

Type of Income Parent/Guardian Spouse Child/Other
Child Support (All children in household)
Welfare Transition(Cash Assistance)
Other Income(SSI, Social Security, Etc

Center Locations: Vetter, Chapman, Massalina, Millville /Margret Lewis, Early Education (East Ave.), Bayou George, Arnold, Home-Based, Rosenwald, Catherine’s House, Community Child Care Partner, Apalachicola, Franklin Co.

Agreement & Terms

I verify that the information provided is true and correct. If there are any changes concerning my status, it is my responsibility to contact Early Education and Care, Inc. I understand the information given on this application can be shared for eligibility determination and service referrals to programs operated through the local school district, Head Start, early care and education providers and the Department of Children and Families. I understand that this application is not complete until I have submitted income verification for my child, and that completing this form does not guarantee placement in the above program.

I have read and fully understand the above Agreement and Certification and agree to its terms.