Head Start/ECEAP/Early Head Start Initial Application

Thank you for your interest in our program for young children. Please complete the following form to begin the application process.

Please list everyone living in the household who may be counted in family size:*

Name	Relationship	Date of Birth

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Concerns and Challenges
Please share your concerns and challenges
Select all that apply to you or your family.
Premature birth, if yes, how early:
Homeless is defined as sharing the housing of other persons due to loss of housing or economic hardship; are living in motels, hotels, trailer parks, or camping grounds due to lack of alternative adequate accommodations; are living living in emergency or transitional shelters (McKinney-Vento Homeless Assistance Act)
Circumstances that you would like to share:
This may qualify you for additional program supports.

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Certification
I certify that the information provided in the Early Learning and Family Services Head Start/ECEAP/Early Head Start Intake Application is accurate and truthful to the best of my knowledge. I authorize and consent to exchanging my household information within the departments in the Opportunity Council agency.*
Type name to certify
Email*
Optional - Verification of Age and Income File Upload
If scanned copies are unavailable, Verification of Age and Income can be mailed or submitted in person. Your application will not be complete until all items have been received.
Upload Verification of Income
Either the last 12 months or the last calendar year.
Max. file size: 25 MB.
Upload Verification of Child’s Age
Birth Certificate or Hospital Certificate
Max. file size: 25 MB.
Phone
This field is for validation purposes and should be left unchanged.

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Initial Application