Head Start Application

Child Applicant

Child Name*

First Middle Last Suffix

Child Date of Birth*

Child Gender*

Child SSN

Child Race*

Hispanic*

English Proficiency - PLEASE USE DROPDOWN TO SELECT.*

Secondary Language - PLEASE USE DROPDOWN TO SELECT.

Secondary Language Proficiency - PLEASE USE DROPDOWN TO SELECT.

Primary Health Coverage - PLEASE USE DROPDOWN TO SELECT.*

Other Health Coverage - PLEASE USE DROPDOWN TO SELECT.

Insurance Number

* REQUIRED IF YOU HAVE INSURANCE

Medical Eligibility - PLEASE USE DROPDOWN TO SELECT.*

Medical Number

Doctor/Medical Home*

Dental Coverage - PLEASE USE DROPDOWN TO SELECT.*

Dental Coverage Number

Dentist/Dental Home*

Does your child have a disability or do you have any concerns about your child's development?*

PLEASE USE DROPDOWN TO SELECT.

Does your child have allergies? - PLEASE USE DROPDOWN TO SELECT.*

If yes, please list:

Seasonal allergies, food allergies, other allergies. Please include medical documentation.

Which program are you applying for? - PLEASE USE DROPDOWN TO SELECT.*

Which Head Start Center are you applying for? - PLEASE USE DROPDOWN TO SELECT.*

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

Disability, Autism, Medications, Certain Behaviors

Required Documentation

Please upload all required documentation. An application without the required supporting documents will not be accepted.

Important Disclosure

By uploading documentation and submitting this electronic application, you certify that the information in this application is true. If any part is false, your participation in this agency's program will be terminated and may be subject to legal action. You also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during normal business hours.

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

Head Start Application

Thank You for Your Interest

Parent/Guardian Information

Family Information

Emergency Contact(s)

Child Applicant

Required Documentation

Important Disclosure

Contact MGCAA

Contact HOGCAC

Helpful Links

Find A Center

Latest Resources

Classroom Assessment Scoring Systems (CLASS) Fall 2026 – RFP

NOTICE OF PUBLIC HEARING DFCS State Plan for Low Income Home Energy Assistance Program (LIHEAP)

NOTICE OF PUBLIC HEARING DFCS State Plan for Community Services Block Grant (CSBG)