Head Start Application

Thank you for your interest in one of the MGCAA Head Start Centers.

Based on your eligibility, you will be placed on the waiting list. Once slots are available, you will be contacted for enrollment. MGCAA Head Start Centers requires an email address for families to participate in our program. Don’t have an email address? Get one free from Gmail.

1Parent/Guardian Information

2Family Information

3Child (Applicant)

Family Information
Number of Parents/Guardians*
Secondary Parent Information
First Last
Date of Birth
Social Security Number
Gender
Email
Enter Email Confirm Email
Mobile Phone
Race
Highest Grade Completed
Primary Language at Home
Employment Status
Pay Frequency
Number in Household*
Please enter a number greater than or equal to 1.
Number in Family*
Please enter a number greater than or equal to 1.
Family members (outside of parent/child applicant) - Blood relation only - Name / DOB / Gender*
If none, please enter N/A
Gross Annual Income*
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?*
Is your family receiving Supplemental Security Income (SSI)?*
Is your family receiving services from WIC?*
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?*
Is at least one parent/guardian an active duty member of the United States military?*
Is at least one parent/guardian a veteran of the United States military?*
Is the custody arrangement a kinship / power of attorney / or foster?*
Documentation will be required before submission.
If other, please list:

Emergency Contact(s)
Name*
First Middle Last Suffix
Relation to Child Applicant*
Mobile Phone*
Living Address*
Street Address Address Line 2 City State ZIP Code
Email
Enter Email Confirm Email
Do we have permission to release your child this emergency contact?*
Name*
First Middle Last Suffix
Relation to Child Applicant*
Mobile Phone*
Living Address*
Street Address Address Line 2 City State ZIP Code
Email
Enter Email Confirm Email
Do we have permission to release your child this emergency contact?*

Child Applicant
Name*
First Middle Last Suffix
Date of Birth*
Month
Day
Year
Gender
SSN
Race*
Hispanic*
English Proficiency*
Secondary Language
Secondary Language Proficiency
Primary Health Coverage*
Other Health Coverage
Insurance Number

* REQUIRED IF YOU HAVE INSURANCE
Medical Eligibility*
Medical Number
Doctor/Medical Home
Dental Coverage*
Dental Coverage Number
Dentist/Dental Home
Does your child have a disability or do you have any concerns about your child's development?*
Does your child have allergies?*
If yes, please list:
Which program are you applying for?*
Which Head Start Center are you applying for?*
Is there anything else you want to tell us about your child?
Required Documentation
Please upload all required documentation. An application without the required supporting documents will not be accepted.
Child's Birth Certificate*
Drop files here or

Max. file size: 256 MB.
Other documents accepted: Proof of Birth, Proof of Paternity/Maternity, Hospital Birth Chart, Health Department Certificate
Child' Social Security Card*
Drop files here or

Max. file size: 256 MB.
Other documents accepted: Letter (showing requested if not received), Tax Document (showing child's name and social)
Immunization Form 3231*
Drop files here or

Max. file size: 256 MB.
Up to date shot records
Medicaid/Insurance Card
Drop files here or

Max. file size: 256 MB.
Print out from website showing number if card not received
Proof of Income (Last 30 Days) - Declaration of Zero Income available on Agency website*
Drop files here or

Max. file size: 256 MB.
Other documents accepted: SNAP Document, SSI Letter, W-2, Check Stubs, TANF Award Letter, Letter from Employer, or Zero Income Form.
Well Child Check/Dental Health Record - Forms available on Agency website*
Drop files here or

Max. file size: 256 MB.
Application will not be accepted without this.
Verification of Income and Housing - Form available on Agency website*
Drop files here or

Max. file size: 256 MB.
Application will not be accepted without this.
Georgia Department of Public Health Form 3300 - Form available on website
Drop files here or

Max. file size: 256 MB.
If applicable
Proof of kinship / power of attorney / foster
Drop files here or

Max. file size: 256 MB.
*REQUIRED for submission - your application will not be processed if this documentation pertains to you and is not submitted.
Disability Documentation
Drop files here or

Max. file size: 256 MB.
If applicable

Thank you for your interest in one of the MGCAA Head Start Centers.

Based on your eligibility, you will be placed on the waiting list. Once slots are available, you will be contacted for enrollment. MGCAA Head Start Centers requires an email address for families to participate in our program. Don’t have an email address? Get one free from Gmail.

Parent/Guardian Information

Family Information

Emergency Contact(s)

Child Applicant

Required Documentation