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Interested in Head Start for
2025–2026?
Fill Out the Pre-Enrollment Application Below

Child Information

Child's first name(Required)

Child's last name(Required)

Child's date of birth(Required)

Month

Day

Year

Gender of child(Required)

Male

Female

Parent's or Guardian's name(Required)

Address(Required)

Language spoken at home(Required)

Custody order in place?(Required)

Yes

Contact Information (Parent/Guardian)

Mother's phone(Required)

Voicemail enabled(Required)

Yes

Father's phone(Required)

Voicemail enabled(Required)

Yes

Best time of day to call(Required)

Email(Required)

How did you find out about our program?

Health and Development of Child

Concerns about child's overall health and/or development(Required)

Yes

If yes, please describe

Is your child receiving services for speech, OT/PT, or have an early intervention teacher?(Required)

Yes

Is your child currently/previously enrolled in a preschool/child care program? (Provide name of program if applicable)(Required)

Does your child have any allergies? If yes, please list them.(Required)

Household Size, Type, and Income

Family Size (family is considered immediate family: parents, children)(Required)

Family Type(Required)

One Parent

Two Parent

Foster

Relative

Family Income (consider all sources of income) Link below for current poverty guidelines chart.(Required)

Below 130% (poverty level)

130%

200%

300%

https://aspe.hhs.gov/sites/default/files/documents/dd73d4f00d8a819d10b2fdb70d254f7b/detailed-guidelines-2025.pdf

Are you currently employed?(Required)

Yes

List name of employer if applicable

This website is supported by Grant Number 03CH011608 from the Office of Head Start within the Administration for Children and Families, a division of the U.S. Department of Health and Human Services. Neither the Administration for Children and Families nor any of its components operate, control, are responsible for, or necessarily endorse this website (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided). The opinions, findings, conclusions, and recommendations expressed are those of Columbia Child Development Program and do not necessarily reflect the views of the Administration for Children and Families and the Office of Head Start.

Interested in Head Start for 2025–2026? Fill Out the Pre-Enrollment Application Below

Child Information

Contact Information (Parent/Guardian)

Health and Development of Child

Household Size, Type, and Income

Interested in Head Start for
2025–2026?
Fill Out the Pre-Enrollment Application Below