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Head Start/Early Head Start Pre-Application
Thank you for your interest in our Head Start/Early Head Start Program. This application is for new students only. In general, eligibility is based on family income at or below the poverty level. Families with other situations including homelessness, disabilities, and children in foster care are also eligible. Due to limited government funding, there are not enough spaces for all eligible children across Clayton/Rockdale Counties. Families are placed on the waitlist if there is not a space available at the time. Once you've completed the pre-application please contact the center where you applied to inquire about your online pre-registration. If you need further guidance on your next steps please feel free to email our coordinators: kallen@claytoncountycsa.org (Clayton) or ajackson@claytoncountycsa.org (Rockdale)

Clayton County Sites                                                  
Brookwood Center (Rex, GA)                  678-788-8920 
South Avenue (Forest Park, GA)            404-363-6710
New Vision Academy (Morrow, GA)      470-610-6340

Rockdale County Sites
Restoration Storehouse (Conyers, GA)  470-975-0030
West Circle  (Conyers, GA)                       470-975-0002


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Email *
Date 
__________
Fecha
*
MM
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DD
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YYYY
Which facility are in you interested in applying?
Please note: You must live in the county of where you are applying.
_____________________________________
¿Qué instalación le interesa aplicar?
Tenga en cuenta: debe vivir en el condado donde está solicitando.
*
Child's Name #1 (Nombre del Niño) (First, Middle, and Last)

Nombre del Niño (Nombre del Niño) (Primer, Segundo y Apellido)
*
Child's Name #2 (Nombre del Niño) (First, Middle, and Last)

Nombre del Niño (Nombre del Niño) (Primer, Segundo y Apellido)
Child Applicant #1 Date of Birth
_____________________________
Fecha de nacimiento del niño
*
MM
/
DD
/
YYYY
Child Applicant #2 Date of Birth
_____________________________
Fecha de nacimiento del niño
MM
/
DD
/
YYYY
Child Applicant #1 Gender
____________________________
Niño Solicitante #1 Género
*
Child Applicant #2 Gender
____________________________
Niño Solicitante #1 Género
Clear selection
Child Applicant #1 Race
_____________________________
Niño Solicitante #1 Raza
*
Child Applicant #2 Race
_____________________________
Niño Solicitante #1 Raza
Clear selection
Hispanic
______________
Hispana o Hispano
*
Living Address (Please include City, State, and Zip)

Dirección de residencia (incluya ciudad, estado y código postal)
Primary Language at Home
______________________________
Idioma principal en el hogar
*
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?

¿Recibe su familia beneficios en efectivo u otros servicios bajo el programa de Asistencia Temporal para Familias Necesitadas (TANF)?
*
Is your family receiving Supplemental Security Income (SSI)?:

¿Recibe su familia Seguridad de Ingreso Suplementario (SSI)?:
*
Is your family receiving SNAP Benefits? (*Food Stamps)

¿Su familia recibe beneficios de SNAP? (*Cupones de alimentos)
*
Gender
_______________
Género
*
Email Address
____________________
Dirección de correo electrónico
*
Home Phone
_________________
Teléfono de casa
Mobile Phone
________________
Teléfono móvil
*
Child's Relationship *
Is your family experiencing homelessness?
___________________________________________
¿Su familia está experimentando la falta de vivienda?
*
Please Answer Yes/No to the Questions Below:
(Responda Sí/No a las siguientes preguntas:)

Housing Information: 
Do you rent your home?
__________________________________
Información de vivienda:
¿Alquilas tu casa?
*
Required
Please Answer Yes/No to the Questions Below:
(Responda Sí/No a las siguientes preguntas:)

Housing Information: 
Do you own your home?
______________________________
Información de vivienda:
eres dueno de tu casa?
*
Required
Please Answer Yes/No to the Questions Below:
(Responda Sí/No a las siguientes preguntas:)

Housing Information: 
Do you live with relatives/friends?
_______________________________________
Información de vivienda:
¿Vives con parientes/amigos?
*
Required
Parent/ Guardian's Name 
___________________________
Nombre del padre o madre / tutor
*
Parent/Guardian's Date of Birth
_________________________________
Fecha de nacimiento del padre/tutor
MM
/
DD
/
YYYY
Parent/Guardian's Social Security Card Number

Número de tarjeta de seguro social del padre/tutor
*
Does your child have a disability or do you have any concerns about your child's development?

¿Su hijo tiene una discapacidad o tiene alguna preocupación sobre el desarrollo de su hijo?
Clear selection
Is there anything else that you want to tell us about your child?
Which program are you applying for? *
Sibling Applicant
Clear selection
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