Apply

We accept applications for Early Head Start (birth to 3) or Head Start (3-5 years).  Head Start and Early Head Start is free for income-eligible qualifying children. 

 You must be income eligible for Head Start.  To be income-eligible, you must have a household income under 100% of poverty, or are homeless, on public assistance, or you have a foster child in your custody. 

 We will then contact you and schedule a time convenient to you to complete an application.  The following documents are required at application time:

Age verification:  birth certificate, hospital record or Medicaid card showing child’s date of birth

 

Thank you for your interest in Head Start,

 

Robin Short | Support Services Coordinator

201 R.M. Davis Parkway, Piqua, OH  45356

V 937-778-5220 | www.councilonruralservices.org

F 937-778-5099, ext. 10405

 

Enrollment is simple! Complete the information below. After submitting the form, you will be contacted by a representative. This individual will answer your questions and explain the requirements to complete the application for the specific center.

 

Parent Name (required)

Address

City

State

Zip

Your Email (required)

Phone Number (required)

Choose Location(s) you are inquiring about

What is the best time to reach you? (required)

Number of Parents/Guardians (required)
One Parent FamilyTwo Parent Family

Primary Language at Home (required)
EnglishSpanish

Total number of family members in household (required)

Gross Annual Income (include child support received into the household. Do not include child support paid out) (required)

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

Is your family receiving Supplemental Security Income (SSI)? (required)
YesNo

Is your family receiving services from WIC? (required)
YesNo

WIC ID (if applicable)

Is your family receiving services under SNAP, formerly known as Food Stamps? (required)
YesNo

Is your child eligible for Medicaid? (required)
YesNo

If yes, what is the Medicaid number?

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

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

How do you want to be contacted? (required)
PhoneEmail

Name of Child #1

Date of Birth of Child #1

Name of Child #2

Date of Birth of Child #2

How did you hear about us? (required)