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Pregnant*
- Yes
- No
Due Date*
MM slash DD slash YYYY
Child 1 Information
Name*
First Last
Birthday*
MM slash DD slash YYYY
Sex*
- Male
- Female
Child Health Coverage*
- Denali Kidcare
- Medicaid
- Private
- Military
- Indian Health Service
- None
Physician*
Dentist*
Primary Language*
Secondary Language
Does your child have any disability or special need? (either diagnosed or suspected)*
- Yes
- No
Do you have concerns about your child’s development?**
- Yes
- No
Explain*
Does your child have an IEP or an IFSP?*
- Yes
- No
Does your child have a sibling in the program?**
- Yes
- No
Add Additional Child?
- Yes
- No

Child 2 Information
Name*
First Last
Brithday*
MM slash DD slash YYYY
Sex*
- Male
- Female
Child Health Coverage*
- Denali Kidcare
- Medicaid
- Private
- Military
- Indian Health Service
- None
Physician*
Dentist*
Primary Language*
Secondary Language
Does your child have any disability or special need? (either diagnosed or suspected)**
- Yes
- No
Do you have concerns about your child’s development?**
- Yes
- No
Explain*
Does your child have an IEP or an IFSP?**
- Yes
- No
Does your child have a sibling in the program?**
- Yes
- No

Parent/Guardian Information
Name*
First Last
Sex*
- Male
- Female
Birthdate*
MM slash DD slash YYYY
Relationship to child(ren)*
- Mother
- Father
- Grandparent
- Foster parent
Employment Status*
Check all that apply
- Full-Time
- Part-Time
- Unemployed
- In School/Training
Estimated Household Income*
- Less Than $25,000
- $25,000-$50,00
- $50,000-$75,000
- $75,000-$100,000
- $100,000+
Did you receive the most recent Alaska PFD?*
- Yes
- No
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Mailing Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone*
Phone Type*
Secondary Phone
Phone Type
May we contact you by text message?*
- Yes
- No
Email*
Primary Language*
Secondary Language
Parental Status*
- One
- Two
Family Type*
- Parent
- Grandparent
- Foster
Number in family*
Number of Children Ages 0 - 35 Months*
Number of Children Ages 3 - 5 Years*
Total Number of Persons In Home*

Parent/Guardian Information continued...
Are you a teen parent?*
- Yes
- No
Has your child previously been enrolled in any Kids’ Corps program?*
- Yes
- No
Family Housing Status*
- Rent
- Own
- Homeless
Has your family experienced homelessness in the past 6 months?*
- Yes
- No
Are you receiving ATAP?*
- Yes
- No
Is your family experiencing a special hardship or crisis?*
- Yes
- No
Explain*
Were you referred by another agency or provider?*
- Yes
- No
Who referred you?*
How did you hear about KCI?*
- Family, Friend or neighbor
- Head Start bus
- KCI brochure/Flier/Rack Card
- Radio
- Door hanger
- Social Media
- Community Event
- Agency referral
- Web Search
What are your parenting goals and expectations that we can support you in?*
How many times a month would best fit your family’s needs for Home Visiting?*
- Prefer twice a month (every other week)
- Prefer four times a month (once a week)
- Either works

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Kids’ Corps, Inc. – - Home Visiting Program
101 Davis St.Anchorage, AK 99508
Phone: 907-339-0154
Fax: 907-339-0148
Email: pat@kcialaska.org

Before submitting your child’s application please note to make the application as simple as possible no additional documents are needed at time of submission. Once application is submitted our Home Visiting Coordinator or one of our Home Visitors will review and follow up with you regarding required documents needed.
What is the best way to contact you to follow up on your child's application?*
- Email
- Phone Call
- Text Message
Electronic Signature*
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Class playing with toys

Class sitting at a desk

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Little girl in purple coat

Two kids smiling

Little girl smiling with toys

Woman reading a book to young girl

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East Center
3710 East 20th Ave. Suite #2
Anchorage, AK. 99508

Phone: (907) 272-0133 • Fax: (907) 272-0312
Email: Contact Us

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