GoEngage | Pre-Registration Application

This pre-registration application is meant to determine possible eligibility for Head Start and Early Head Start programs. If it looks like your child will qualify for Head Start, you will be contacted by a nearby agency with additional information.

I am applying for

My Child A family member who is pregnant

Parent / Guardian Information

Parent First Name Parent Last Name Home Phone # Used only for contacting qualifying applicants. Mobile Phone # Is there another number to reach you by? Mobile Provider Email Date of Birth In the format 'mm/dd/yyyy' Parent's Gender

Male Female

Are you currently pregnant?

Yes No

Do you currently have a child of eligible age?

Yes No

Street Address Enter your address. City Enter your city. State Enter your state. Zip Enter your zip code. Street Address Line Two (Optional)

Child's Information

Child's First Name Child's Last Name Child's Date of Birth In the format 'mm/dd/yyyy' Child's Gender:

Male Female

Has this child been enrolled in Head Start or Early Head Start in the past?

Yes No

Have you ever applied for this child before or been placed on a waiting list?

Yes No

Does this child have a disability?

Yes No

What qualifies as a disability?

For a general definition about what qualifies as a disability, visit this link. If you feel your child may qualify but are unsure, select "Yes". Exact qualification status can be determined later.

Family Information

Parent Type:

SPF (Single Parent Father Figure)

SPFP (Single Parent Father w/Partner)

SPM (Single Parent Mother Figure)

SPMP (Single Parent Mother w/Partner)

TPF (Two Parent Family)

What is a parent type?

Parent type describes the relationship of the parent(s) and child. Note that the parent does not have to be a biological relative to qualify as a parent figure.

Homeless

Yes No

Has this child been in or is currently in foster care?

Yes No

Have you received any financial assistance in the last year?

Yes No

SSI?

Yes No

What is SSI?

Supplemental Security Income (SSI) pays monthly benefits to people and children with limited income and resources who are disabled, blind, or age 65 or older. To read more about SSI, click here.

TANF?

Yes No

What is TANF?

The Temporary Assistance for Needy Families (TANF) program is designed to help needy families achieve self-sufficiency. States receive block grants to design and operate programs that accomplish one of the purposes of the TANF program. To read more about TANF, click here.

SNAP?

Yes No

Have you already applied for a specific Head Start location?

Yes No

Applied for Location (Optional) The name of the facility applied too, if you have already applied. Type of Program Applied for (Optional) Leave this blank or select "have not applied" if you did not fill out the previous field.

Full Day

Part Day

Have not applied

Estimated annual income Number of children in your family: Number of adults in your family:

Head Start Pre-Registration Application

Parent / Guardian Information

Child's Information

What qualifies as a disability?

Family Information

What is a parent type?

What is SSI?

What is TANF?

Preferred centers