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Head Start Early Head Start Application

Please complete the form below to begin your application process for the Early Childhood Education with Guardian Angel. Please be sure to provide current and accurate information regarding your child and family, as this will ensure the application process goes as quickly as possible. Completing this form is the first step in the application process. A member of our team will be in contact with you after your interest form is submitted. If you need to speak with a staff member sooner or have an urgent matter, please call us at 314-231-3188.

Parent/Guardian

Name:(Required)

First Last

Date of Birth:(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification:(Required)

Female

Male

Email Address:(Required)

Enter Email Confirm Email

Mobile Phone Number:(Required)

Opt in for Text Messages:(Required)

Home Phone Number

Work Phone Number

Work phone Ext.

Highest Grade Completed(Required)

Employment Status(Required)

Relationship to Child(Required)

Do you have Child Custoday?(Required)

Is your family experiencing homelessness?(Required)

Live with Family?(Required)

Living Address(Required)

Street Address Address Line 2 City State ZIP Code

Mailing Address (if different than living address)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is there another parent/guardian in the family?(Required)

Additional Parent/Guardian

Please list Additional Parent/Guardian below. (if applicable)

Name(Required)

First Last

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Email Address(Required)

Enter Email Confirm Email

Phone number(Required)

English Language Proficiency(Required)

Highest Grade Completed(Required)

Employment Status(Required)

Relationship to Child(Required)

Live with Family?(Required)

Family Information

Number of Parents/Guardians(Required)

Relationship to Participant(s)(Required)

Primary Language at Home:(Required)

Number of family members:(Required)

Please enter a number from 1 to 20.

Gross Annual Income:(Required)

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?(Required)

Is your family receiving Supplemental Security Income (SSI)(Required)

Is your family receiving services from WIC?(Required)

WIC ID (if applicable)(Required)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?(Required)

Is at least one parent/guardian an active duty member of the United States military?(Required)

Is at least one parent/guardian a veteran of the United States military?(Required)

Emergency Contact Information

Emergency Contacts(Required)

First Last

Emergency Contact Phone number:(Required)

Emergency Contact Address(Required)

Street Address Address Line 2 City State ZIP Code

What is the Emergency Contacts' Relationship to Child(Required)

May we contact this emergency contact if we are unable to reach you"(Required)

May the child be released to this emergency contact?(Required)

Child (Applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #2 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?

Yes

Child #3 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #4 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #5 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #6 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #7 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #8 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #9 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Do you have an additional applicant?(Required)

Yes

Child #10 (applicant)

Name(Required)

First Middle Last

Nick Name

First

Date of Birth(Required)

Race(Required)

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification(Required)

Female

Male

Primary Health Coverage(Required)

Medicaid Eligibility(Required)

Name of Primary Doctor or Medical Clinic/Group

Name of Dentist or Dentist Clinic/Group

Does your child have a disability or do you have any concerns about your child's development(Required)

Is there anything else you want to tell us about your child?

Does the applicant (Child) have sibling(s) that are NON-applicants?(Required)

Siblings

Only input siblings who are not applicants.

Name (Sibling #1)

First Last

Date of birth (sibling #1)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #1)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #2

Name (Sibling #2)

First Last

Date of birth (sibling #2)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #2)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #3

Name (Sibling #3)

First Last

Date of birthday (sibling #3)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #3)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #4

Name (Sibling #4)

First Last

Date of birth (sibling #4)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #4)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #5

Name (Sibling #5)

First Last

Date of birth (sibling #5

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #5)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #6

Name (Sibling #6)

First Last

Date of birth (sibling #6)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #6)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #7

Name (Sibling #7)

First Last

Date of birth (sibling #7)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #7)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #8

Name (Sibling #8)

First Last

Date of birth (sibling #8)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #8)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #9

Name (Sibling #9)

First Last

Date of birth (sibling #9)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #9)

Female

Male

Additional NON-applicant Sibling

Add additional sibling (NON-applicant)

Additional Siblings

Sibling #10

Name (Sibling #10)

First Last

Date of birth (sibling #10)

Race

Black/African American

Hispanic/Latino/Latinx

Asian

Native American/Alaskan Native

Biracial/Multi-Racial

Native Hawaiian/Other Pacific Island

Unspecified

White/Caucasian

Other

Gender Self-Identification (sibling #10)

Female

Male

Before you submit your appliication:

I give Guardian Angel Settlement Association (and those they authorize), permission to use any photos or videos of me on either of their campuses in any format; including social media, websites and print.(Required)

Yes

Mission Moment

Darrionna’s Story

Darrionna is a single mother of two children. Most mornings, she wakes up tired after a restless sleep. The stresses of providing for her family seem to always catch up with her at night – and sometimes those stresses bring her to tears.

Apply Now

Head Start Early Head Start Application

Parent/Guardian

Additional Parent/Guardian

Family Information

Emergency Contact Information

Child (Applicant)

Child #2 (applicant)

Child #3 (applicant)

Child #4 (applicant)

Child #5 (applicant)

Child #6 (applicant)

Child #7 (applicant)

Child #8 (applicant)

Child #9 (applicant)

Child #10 (applicant)

Siblings

Additional Siblings

Additional Siblings

Additional Siblings

Additional Siblings

Additional Siblings

Additional Siblings

Additional Siblings

Additional Siblings

Additional Siblings

Before you submit your appliication:

Mission Moment

Darrionna’s Story

First Step on the Path to Possible

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