In addition to completing the application below, copies of the following must be provided:

• Proof of Income for all household members
• Child’s birth certificate or hospital birth record
• Copy of child’s current immunization record
• Copy of subsidy document (if received)-EHS-Child Care Center applicant’s only
• Copy of records if your child has been diagnosed with a disability–Evaluations, IEP or IFSP

Information can be returned via email to Brittany Bailey at brittany.bailey@liftca.org

Please click on the red button below for additional guidance.

If you have questions or need additional assistance, please call 1-866-326-7581.

Please fill in the form below to apply for LIFT CAA’s Head Start program.

                

                        
Program Information
Please select the program you are applying for*
Head Start (age 3 to 5 years)Early Head Start - Center Base (birth to 36 months)Early Head Start-CC - Center Base (birth to 36 months)
Child Information
Child's Name*

                            
                            
                                                    First
                                                    
                                                
                            
                                                    Middle
                                                    
                                                
                            
                                                            Last
                                                            
                                                        
                            
                        
Child's Date of Birth*

                            
                            MM slash DD slash YYYY
                        
                        
Child's Gender*

			

				
				Male
			
			

				
				Female
			
Child's Race

			

				
				White
			
			

				
				Black
			
			

				
				American Indian
			
			

				
				Hispanic
			
			

				
				Asian (please specify)
			
			

				
				
			
Hispanic?
YesNo
Please specify "Asian"
 
What language does this child speak at home? Primary Language:*
 
If English is the second language, how well does this child speak English?

			

				
				Very well
			
			

				
				Well
			
			

				
				Not well
			
			

				
				Not at all
			
Family / Guardian Information
Mailing Address*    
                    

                         
                                        Street Address
                                        
                                   
                                        Address Line 2
                                        
                                    
                                    City
                                    
                                 
                                        State
                                        AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
                                      
                                    ZIP Code
                                    
                                
                    

                
Is your mailing address different from your living address?*

			

				
				Yes
			
			

				
				No
			
Living Address    
                    

                         
                                        Street Address
                                        
                                   
                                        Address Line 2
                                        
                                    
                                    City
                                    
                                 
                                        State
                                        AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific
                                      
                                    ZIP Code
                                    
                                
                    

                
Home Phone
Work Phone
Cell Phone
Message Phone
Email

                            
                        
Have you, your spouse or any of your children previously been enrolled in a Head Start / Early Head Start or other child development program or daycare?*

			

				
				Yes
			
			

				
				No
			
If yes, specify which program(s) this child has attended date(s) of attendance, or if applying child is presently enrolled.

								
								Early Head Start
							

								
								Head Start
							

								
								OPAT
							

								
								Children First
							

								
								Daycare
							
Start Date of Early Head Start

                            
                            MM slash DD slash YYYY
                        
                        
End Date of Early Head Start

                            
                            MM slash DD slash YYYY
                        
                        
Start Date of Head Start

                            
                            MM slash DD slash YYYY
                        
                        
End Date of Head Start

                            
                            MM slash DD slash YYYY
                        
                        
Start Date of OPAT

                            
                            MM slash DD slash YYYY
                        
                        
End Date of OPAT

                            
                            MM slash DD slash YYYY
                        
                        
Start Date of Children First

                            
                            MM slash DD slash YYYY
                        
                        
End Date of Children First

                            
                            MM slash DD slash YYYY
                        
                        
Start Date of Daycare

                            
                            MM slash DD slash YYYY
                        
                        
End Date of Daycare

                            
                            MM slash DD slash YYYY
                        
                        
Specify which daycare
 
Which LIFT CAA Head Start / Early Head Start / Early Head Start-CC center are you applying for?
Antlers Early Head Start/Early Learning CenterAntlers I & II Head StartBattiest Head StartBoswell I & II Head StartBroken Bow Early Learning CenterBroken Bow I Head StartBroken Bow III Head StartClayton I & II Head StartForest Grove I & II Head StartFort Towson Head StartCabbage PatchHaworth Head StartHorace Mann I, II & IIIHugo Early Head StartHugo Early Learning CenterHugo II Head StartHugo IV Head StartIdabel I, II & III Head Start/Early Head Start/Early Learning CenterIdabel Early Head Start/Early Learning CenterRattan I Head StartRattan II & III Head StartSoper I & II Head StartThe Learning TreeValliant I & II Head Start
Medical Conditions
Has this child been identified as having, or is suspected to have, any of the following:
Asthma*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Asthma Identified

                            
                            MM slash DD slash YYYY
                        
                        
Asthma Evaluated By:
 
Autism*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Autism Identified

                            
                            MM slash DD slash YYYY
                        
                        
Autism Evaluated By:
 
Autism Severity
 
Emotional/Behavior Disorder*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Emotional/Behavior Disorder Identified

                            
                            MM slash DD slash YYYY
                        
                        
Emotional/Behavior Disorder Evaluated By
 
Food Allergy*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Food Allergy Identified

                            
                            MM slash DD slash YYYY
                        
                        
Food Allergy Evaluated By
 
Aggressive Behavior*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Aggressive Behavior Identified

                            
                            MM slash DD slash YYYY
                        
                        
Aggressive Behavior Evaluated By
 
Health Impairment*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Health Impairment Identified

                            
                            MM slash DD slash YYYY
                        
                        
Health Impairment Evaluated By
 
Type of Health Impairment
 
Hearing Impairment*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Hearing Impairment Identified

                            
                            MM slash DD slash YYYY
                        
                        
Hearing Impairment Evaluated By
 
Intellectually Disabled*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Intellectually Disabled Condition Identified

                            
                            MM slash DD slash YYYY
                        
                        
Intellectually Disabled Condition Evaluated By
 
Down Syndrome*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Down Syndrome Identified

                            
                            MM slash DD slash YYYY
                        
                        
Down Syndrome Evaluated By
 
Down Syndrome Severity
 
Orthopedic Impairment*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Orthopedic Impairment Identified

                            
                            MM slash DD slash YYYY
                        
                        
Orthopedic Impairment Identified By
 
Speech/Language Impairment*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Speech/Language Impairment Identified

                            
                            MM slash DD slash YYYY
                        
                        
Speech/Language Impairment Evaluated By
 
Seizures/Traumatic Brain Injury*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Seizures/Traumatic Brain Injury Identified

                            
                            MM slash DD slash YYYY
                        
                        
Seizures/Traumatic Brain Injury Evaluated By
 
Visual Impairment*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Visual Impairment Identified

                            
                            MM slash DD slash YYYY
                        
                        
Visual Impairment Evaluated By
 
Visual Impairment Severity
 
Cerebral Palsy*

			

				
				No
			
			

				
				Suspected
			
			

				
				Identified
			
Date Cerebral Palsy Identified

                            
                            MM slash DD slash YYYY
                        
                        
Cerebral Palsy Evaluated By
 
Cerebral Palsy Severity
 
Additional Family Information
Which of the following descriptions best fit the child's family (choose only one)*

			

				
				Two Parent Family
			
			

				
				Single Parent Family
			
			

				
				Single Parent Family Living with Partner
			
			

				
				Foster Family
			
			

				
				Other Relatives
			
List all household members and their relationship to the applying child.  Please list only the people living in the home.
How many adults are in your family?*
Please enter a number from 1 to 6.
Primary Adult*

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (primary adult)*
 
Date of birth (primary adult)*

                            
                            MM slash DD slash YYYY
                        
                        
Secondary Adult

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (secondary adult)
 
Date of birth (secondary adult)

                            
                            MM slash DD slash YYYY
                        
                        
Adult Family Member #3

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (adult family member #3)
 
Date of birth (adult family member #3)

                            
                            MM slash DD slash YYYY
                        
                        
Adult Family Member #4

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (adult family member #4)
 
Date of birth (adult family member #4)

                            
                            MM slash DD slash YYYY
                        
                        
Adult Family Member #5

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (adult family member #5)
 
Date of birth (adult family member #5)

                            
                            MM slash DD slash YYYY
                        
                        
Adult Family Member #6

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (adult family member #6)
 
Date of birth (adult family member #6)

                            
                            MM slash DD slash YYYY
                        
                        
How many children are in your family?*
Please enter a number from 0 to 10.





Additional Child #1

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #1)
 
Date of birth (additional child #1)

                            
                            MM slash DD slash YYYY
                        
                        






Additional Child #2

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #2)
 
Date of birth (additional child #2)

                            
                            MM slash DD slash YYYY
                        
                        






Additional Child #3

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #3)
 
Date of birth (additional child #3)

                            
                            MM slash DD slash YYYY
                        
                        






Additional Child #4

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child  #4)
 
Date of birth (additional child #4)

                            
                            MM slash DD slash YYYY
                        
                        






Additional Child #5

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #5)
 
Date of birth (additional child #5)

                            
                            MM slash DD slash YYYY
                        
                        






Additional Child #6

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #6)
 
Date of birth (additional child #6)

                            
                            MM slash DD slash YYYY
                        
                        






Additional child #7

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #7)
 
Date of birth (additional child #7)

                            
                            MM slash DD slash YYYY
                        
                        






Additional child #8

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #8)
 
Date of birth (additional child #8)

                            
                            MM slash DD slash YYYY
                        
                        






Additional child #9

                            
                            
                                                    First
                                                    
                                                
                            
                            
                                                            Last
                                                            
                                                        
                            
                        
Relationship to applying child (additional child #9)
 
Date of birth (additional child #9)

                            
                            MM slash DD slash YYYY
                        
                        




What is the highest level of education the primary adult has completed?
No school completed1st - 8th grade9th - 12th grade (no diploma)High school graduate or GEDSome collegeAssociate degreeBachelor degreeMaster or Doctorate degree
Based on the income verification you attached, how often do you get paid? (e.g. weekly, monthly)
 
If employed, is it

			

				
				Part time
			
			

				
				Full time
			
Does your family receive any of the following types of services or financial assistance?

								
								Public Assistance/Welfare (Ex.: TANF)
							

								
								Supplemental Security Income (SSI)
							

								
								Foster Care/Adoption Subsidy
							

								
								Living Assistance Provided By Family or Friends
							

								
								`Medical Financial Assistance (Ex.: SoonerCare/Medicaid/Medicare)
							

								
								Other Health Insurance/Coverage
							

								
								SNAP
							

								
								WIC
							

								
								Child Support/Alimony
							

								
								Title XX Day Care Assistance/Subsidy
							

								
								Other
							
Please specify "other" types of services or financial assistance not specified above
Title XX Day Care Assistance/Subsidy amount
Is anyone in your household an active US military member?*

			

				
				Yes
			
			

				
				No
			
Is anyone in your household a Veteran of the US military?*

			

				
				Yes
			
			

				
				No
			
Do you currently live with family or friends due to economic hardship?*

			

				
				Yes
			
			

				
				No
			
Is the situation (living with family or friends) temporary, or permanent?

			

				
				Temporary
			
			

				
				Permanent
			
CAPTCHA
I certify the information provided in support of this application is accurate and truthful to the best of my knowledge. I give my consent for LIFT CAA Head Start/Early Head Start/Early Head Start-Child Care staff to look up, print and attach to this application my child's Oklahoma vaccination record from the state immunization website (OSIIS).
Signature*
Date Signed*

                            
                            MM slash DD slash YYYY