Home Visiting Application Step 1 of 5 20% Pregnant* Yes No Due Date* MM slash DD slash YYYY Child 1 InformationName* 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 InformationName* 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 InformationName* 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*Select One...MobileHomeSecondary PhonePhone TypeSelect One...MobileHomeMay 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 Digital SignatureKids’ Corps, Inc. – - Home Visiting Program 101 Davis St.Anchorage, AK 99508 Phone: 907-339-0154Fax: 907-339-0148Email: 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* CAPTCHA Δ
