Skip to content
Offering over 50 years of quality care and education!
Make a Donation
Become a Volunteer
Facebook page opens in new window
Early Education and Care Inc.
We are a non-profit organization providing early education for children ages 0 to 5.
Home
About Us
Director’s Message
Board of Directors
Annual Reports
Programs
Head Start / Early Head Start
Home Base
DCF Childcare Training
Get Involved
Donate
Volunteer
Sponsors
Events
Upcoming Events
Kidfest
Employment
Contact
Home
About Us
Director’s Message
Board of Directors
Annual Reports
Programs
Head Start / Early Head Start
Home Base
DCF Childcare Training
Get Involved
Donate
Volunteer
Sponsors
Events
Upcoming Events
Kidfest
Employment
Contact
Headstart Online Application
Headstart Application
Step
1
of
4
25%
PARENT/GUARDIAN INFORMATION
Your Name
First
Last
Your Phone
Your Email Address
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Marital Status
Single
Married
Divorced
Separated
Widowed
Do you receive SNAP benefits?
Yes
No
Are you currently in any type of school or training?
Yes
No
Do you have a high school diploma or GED?
Yes
No
If you are a guardian, do you receive cash assistance for the child(ren) in your care?
Yes
No
Do you have a referral from another agency? If so, please attach documentation.
Yes
No
Are any of your children diagnosed with a special need or disability?
Yes
No
If yes, which children:
Do you have concerns for your children’s health or development?
Yes
No
If yes, which children:
Children information
Name
DOB
Sex
Relationship to child
Medicad
In School? Where?
Add
Remove
ADULTS IN HOUSEHOLD
Name
DOB
Sex
Employer
Hrs Worked
School
Hourly Wage
Add
Remove
Income Information
Type of Income
Child Support (All children in household)
Welfare Transition (Cash Assistance)
Other Income (SSL, Social Security, Etc)
Parent/Guardian
Spouse
Child/Other
Parent/Guardian
Spouse
Child/Other
Add
Remove
Parent/Guardian
Spouse
Child/Other
Center Location
Please select your preferred location
Chapman
Forest Park
Early Education
Pananavilla
Arnold
Franklin
AGREEMENT & TERMS
(Required)
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.
CAPTCHA
Go to Top
