PACE Application

Head Start Pre-Application

Thank you for your interest in Pace Head Start. This application is for new students only. Head Start does not operate on a first come, first served basis; children are awarded points and the children with the highest points are enrolled first. Once you've completed the application a staff member will contact you. If you have not heard from our staff within 7 days please feel free to call us.

First Name *:
Parent / Guardian

Last Name *:

Birthday *:

Gender:

Email Address:

Confirm Email Address:

Mobile Phone:

Opt In for Text Messages:

Home Phone:

Work Phone:

Child's Relationship:


Address
Is your family experiencing homelessness?:

Living Address *:

Address Line 2:

City *:

State *:

ZIP *:


Family Information
Number of Parents/Guardians:

Relationship to Participant(s):

Primary Language at Home:

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)?:


Child Applicant One
First Name *:

Last Name *:

Nickname:

Birthday *:

Gender:

Race:

Hispanic:

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

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


Child Applicant Two
First Name *:

Last Name *:

Nickname:

Birthday *:

Gender:

Race:

Hispanic:

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

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


Location Preferences for Child
Which program are you applying for? *:


Sibling Applicant
First Name *:

Last Name *:

Birthday *:

Gender:

Clayton County Community Services Authority, Inc. is a non-profit community action agency established in 1966 designated to provide high quality human services in Clayton, Henry and Fayette counties.