Early Head Start Application Step 1 of 5 20% Program OptionsPlease 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 MM slash DD slash YYYY 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 InformationParent/Guardian* First Name Last Name Birth Date* MM slash DD slash YYYY * 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*CellHomeWorkSecondary PhoneTypeCellHomeWorkMay 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* MM slash DD slash YYYY * 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Mailing Address (if different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone*Type*CellHomeWorkSecondary PhoneTypeCellHomeWorkMay 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 DocumentationPlease 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 printout, SSI, LES, pay stubs etc.) Child's Birth Certificate Child Immunization Record Physical Exam Kids’ Corps, Head Start 3710 E. 20th Ave. Suite 2 Anchorage, AK 99508 Fax: 907-222-1232 Email: miriam@kcialaska.org Miriam Vasquez-Mateo, Enrollment Specialist 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* CAPTCHA
