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Kids Corp. Inc.

Alaska Based Head Start Agency

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907.279.2021
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Head Start Application

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Options & Locations
Please check all interested centers & options.

*Parents must be employed or enrolled in school or a job training program to be eligible for full day services
Full Day (8:30am-3:00pm) Monday - Friday · Part Year (September-May) Preschool
- Ridgeline Center Only (185 Ridgeline Loop)
Half Day (9:30am-1:30pm) Monday-Friday · Part Year (September-May) Preschool
- East Center (3710 E. 20th Ave, Suite 2)
- Mountain View Center (3350 Commercial Dr. # 106)
- Muldoon Center (1251 Muldoon Rd Ste. 112)
Bus service not available for half day program
Full Day* (up to 10 hours/day) · Full Year Preschool
- East Center Only (3710 E. 20th Ave, Suite 2)
Fees Apply · Child Care Assistance Required

Child Information
Child's Name*
First Last
Child's Birth Date*
Date Format: MM slash DD slash YYYY
Child's Sex*
- Male
- Female
Child's Primary Language*
Child's Secondary Language
Does your child have any disability or special need? (either diagnosed or suspected)*
- Yes
- No
Explain*
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
Sibling Name*
First Last

Parent/Guardian Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
Sex*
- 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
Mailing Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone*
Phone Type*
Secondary Phone
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 Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
Sex*
- Male
- Female
Employment Status*
- Full-Time
- Part-Time
- Unemployed
- In School/Training
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*
Phone Type*
Secondary Phone
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
Number in Family*
Number of Children Ages 0 - 35 Months*
Number of Children Ages 3 - 5 Years*
Total Number of Persons In Home*

Do you need care for your child while you are at work or school?*
- Yes
- No
Who currently provides care for your child?*
Has your child previously been enrolled in another Early Head Start or 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
- Community Event
- Agency referral
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 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*

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

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