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Kids Corp. Inc.

Alaska Based Head Start Agency

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Early Head Start Application

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Program Options
Please check all options you are interested in.
- Home Based Option
- Center Based Option
Weekly visits in the family home focusing on child development and strengthening parent- child relationships. Monthly group socialization activities for parents and children. Serves families with children prenatal to 3 years

There is no cost for this program.
Full day/Full year child development services in a quality early learning environment for children needing full time care. Serves families with children age 4 months to 3 years. Parents must be employed or enrolled in school or a job training program to be eligible.

Fees apply for this program. Child Care Assistance required.
Early Head Start Contact Information:

3350 Commercial Drive Suite 100
Phone: 222-1222 Fax: 222-1232

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

Family Information
Parent/Guardian*
First Name Last Name
Birth Date*
*
- Male
- Female
Employment/School Status*
- Full-Time
- Part-Time
- Unemployed
- In School/Training
(check all that apply)
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*
Type*
Secondary Phone
Type
May we contact you by text message?*
- Yes
- No
Email*
Primary Language*
Secondary Language
Did you receive the most recent Alaska PFD?*
- Yes
- No
Parental Status*
- One
- Two
Parent/Guardian*
First Name Last Name
Birth Date*
*
- Male
- Female
Employment Status*
- Full-Time
- Part-Time
- Unemployed
- In School/Training
(check all that apply)
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Type*
Secondary Phone
Type
May we contact you by text message?*
- Yes
- No
Email*
Primary Language*
Secondary Language
Did you receive the most recent Alaska PFD?*
- Yes
- No
Family Type*
- Parent
- Grandparent
- Foster
- Other

Family Information (continued)
Number in Family*
Number of Children Ages 0 - 35 Months*
Number of Children Ages 3 - 5 years*
Total Number of Persons In Home*
Are you a teen parent?*
- Yes
- No
Do you need care for your child while you are at work or school?*
- Yes
- No
If yes, who currently provides care for your child?*
Has your child previously been enrolled in another Early Head Start 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
ATAP Case Number
Is your family experiencing a special hardship or crisis?*
- Yes
- No
Explain*
Were you referred by another agency or provider?*
- Yes
- No
Who?*
How did you hear about KCI?*
- Friend or neighbor
- Head Start bus
- KCI brochure
- Radio
- Door hanger
- Agency referral
- Community event
What Event*
If a Head Start bus is not available, can you provide transportation for your child?*
- Yes
- No

Documentation
Please scan, drop off, fax or mail copies of the following documentation:
- Income verification from all cash income sources for 12 months (W2, 1040 Tax Forms, child support, unemployment benefits, ATAP printouts, SSI, LES, pay stubs, etc.)
- Child's Birth Certificate
- Child Immunization Record
- Physical Exam
Early Head Start
3350 Commercial Drive, Suite 100
Anchorage, AK 99501
Phone: 907-222-1222
Fax: 907-222-1232
Email: sellis@kcialaska.org Selina Ellis, Early Head Start Center Director/Family Advocate

I certify that this information is true. If any part is false, my participation in this agency’s programs may be terminated and I may be subject to legal action. I 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.

By typing my name in the field below, I certify that the information provided in this application packet contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge.
Electronic Signature*

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Brochure and application for the Alaska Head Start Association (AHSA) Alaska Head Start Brochure & Application

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