Head Start

Parent/Guardian's name*

First NameLast Name

Parent/Guardian's date of birth*

MonthDayYear

Parent/Guardian's gender*

Parent/Guardian's social security number*

Is the Parent/Guardian receiving WIC?*

YesNo

Does the Parent/Guardian receive SNAP/Food Stamps?*

YesNo

Parent/Guardian's preferred language*

EnglishSpanishOther

Other language(s) the Parent/Guardian speaks

Is the Parent/Guardian Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.*

Yes, HispanicNo, not Hispanic

Select one or more races from the following five racial groups. Please check all boxes that apply to the Parent/Guardian; check at least one box.*

AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.ASIAN: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.BLACK OR AFRICAN AMERICAN: A person having origins in any of the Black racial groups of Africa.WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Parent/Guardian's highest education completed*

Parent/Guardian's employment status*

Employed full-timeEmployed part-timeUnemployed

Parent/Guardian's cell phone

Please enter a valid phone number.

Parent/Guardian's alternate phone

Please enter a valid phone number.

Parent/Guardian's email

example@example.com

A valid cell phone number and email address are necessary for full functionality of ParentSquare, our school-to-family messenger app. If you do not provide this information, you may miss important messages from the school.

Many companies (Google, Yahoo, etc.) provide email addresses free of charge.

Parent/Guardian's employer*

Parent/Guardian's work phone*

Please enter a valid phone number.

Parent/Guardian's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian's previous address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Number of people in household*

Parent/Guardian's marital status*

MarriedUnmarried

Family type*

Single-parent familyTwo-parent familyOther

Current housing type*

RentOwnOther

Monthly Utility Expenses
Heat:  $    average monthly*
Gas and electric: $   average monthly*
Water and sewer: $   average monthly*
Trash removal: $   average monthly*
Renter's or Homeowner's insurance: $   average monthly*

Has the family moved in the last 24 months?*

YesNo

Is the Parent/Guardian a member of the U.S. military on active duty?*

YesNo

Head Start Application

Student Information

Parent/Guardian Information

Additional Parent/Guardian Information

Supporting Documents