Welcome to the Northeast Washington Early Childhood Program's On-line Application
Parent/Guardian
Please Complete All the Required Information
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Email Address (Required)
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
English
French
Russian
Spanish
Ukrainian
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Self-employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Address
Please include both your mailing and physical (living) address.
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
Click here
to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Only complete this section if the Secondary Adult is currently living in the home, supported by the same income, or related by blood, marriage, or adoption.
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Email Address
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
Home Phone
Work Phone
Ext.
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
English
French
Russian
Spanish
Ukrainian
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Self-employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
American Sign Language
English
French
Russian
Spanish
Ukrainian
Is another language being acquired or learned at home?
Yes
No
Number in Household
Number in Family
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Is at least one parent/guardian an active duty member of the United States military?
Yes
No
Is at least one parent/guardian a veteran of the United States military?
Yes
No
Child (Applicant)
If your child has an IEP or IFSP in place, please place the diagnosis, along with the service beginning and end dates in the notes section below.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
English
French
Russian
Spanish
Ukrainian
Primary Health Coverage
Medicaid
No Insurance
Other
Private Health Insurance
Doctor/Medical Home
CHAS Medical Records
Chewelah Associated Physicians
Coeur d'Alene Pediatrics
Deer Park Family Care
Kaiser Permanente
Kaniksu Community Health
Lake Roosevelt Community Health
Mt. Spokane Pediatrics
Multicare Rockwood Pediatrics
NEW Health Plan
Newport Hospital & Health
Newport Vision
Northwest Ears, Nose, and Throat
Northwest Pediatric Ophthamology
Northwest Spokane Pediatrics
Providence NEWMG
Providence Pediatric Pulmonology
Providence Pediatrics Northpoint
Providence Pediatrics South
Spokane Ears Nose, Throat
Spokane Eye Clinic
Three Rivers Family Medicine
Vision Source
Dentist/Dental Home
Apple Valley Dental
Banich Family
Camas Center Clinic
CHAS Medical Records
Children's Choice Peditric Denti
Children's Dental Village
Colville Pediatrics
Dance Dentistry for Kids
Healthy Expressions
Kaniksu Community Health
Kidd's Place
Lake Roosevelt Community Health
Little Smiles Pediatrics Dental
NEW Health Plan
Newport Family Dental
Sandpoint Kids Dentistry
Spokane Pediatrics Dentistry
ToothSavers of Washington
Woodland Family Dental
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Head Start
Preschool for ages 3-5 years old
Early Child Education & Assistance
Preschool for ages 3-5 years old
Smart Start Learning Center
Learning Center for ages 18 months to 12 years old
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
Are there other children in the family?
Add a Sibling
Thank you for completing our on-line application. An Enrollment Specialist will be in contact with you within the next 3 to 5 working days.
Required information is missing, see above.