Application for Program Year 2022-2023

Congratulations! You are taking very important steps towards your child's successful future.

Enrollment is based on need, we are not a first come, first served program.
The information you provide to us will only be used to determine your child’s eligibility for services and will be kept confidential.
Proof of income is required to determine eligibility and is part of the application process.

Completing this application does not guarantee placement.

FOR NEW FAMILIES ONLY

You do not need to fill this out if you have an application with us already or if your child is continuing for another year with our program.
If you have any questions or want help filling out the application, please call us for help:
715-845-2947 Fax: 715-845-0909
E-Mail: nikkiparker@mccdahs.org

Si necesita esta aplicación en español, por favor haga clic aqui:

*Marathon County Child Development Agency, Inc. does not discriminate on the basis of race, sex, age, color, national origin, religion, or disabilities in the provision of services & employment.*

First Name (Required)

Middle Name

Last Name (Required)

Nickname

Birthday (Required)

Gender

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

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.

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Is your family experiencing homelessness?

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

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

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

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.

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Household

Number in Family

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

WIC ID (if applicable)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

Dentist/Dental Home

Does your child have a disability or do you have any concerns about your child's development?

Is there anything else you want to tell us about your child?

Which program are you applying for? (Required)

Location Preference

1st Location Preference

2nd Location Preference

3rd Location Preference

- Your Address - Available Locations

Click a location on the map to see more info

Click here to find a provider in your area.

Do you want to apply now for another child in your family?

Add Another Applicant

Are there other children in the family?

Add a Sibling

PLEASE READ THE STATEMENTS BELOW CAREFULLY BEFORE SUBMITTING

For enrollment purposes, I understand that MCCDA Head Start may need to coordinate programming with my local school district, WI Immunization Registry, and/or day care provider for transportation, placement, 4K registration, scheduling, and other home visitation programs. By submitting, I verify that I am the parent/legal guardian of this child and that the information provided is correct and complete to the best of my knowledge. I further understand that if I knowingly provide false information that my participation in this agency's program 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.

REMEMBER, AN INCOMPLETE APPLICATION WILL DELAY PROCESSING-SEE INTRODUCTORY INSTRUCTIONS FOR DETAILS

Required information is missing, see above.

Application for Program Year 2022-2023

Congratulations! You are taking very important steps towards your child's successful future.

Completing this application does not guarantee placement.

FOR NEW FAMILIES ONLY

You do not need to fill this out if you have an application with us already or if your child is continuing for another year with our program.
If you have any questions or want help filling out the application, please call us for help:
715-845-2947 Fax: 715-845-0909
E-Mail: nikkiparker@mccdahs.org

Si necesita esta aplicación en español, por favor haga clic aqui:

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings

PLEASE READ THE STATEMENTS BELOW CAREFULLY BEFORE SUBMITTING

REMEMBER, AN INCOMPLETE APPLICATION WILL DELAY PROCESSING-SEE INTRODUCTORY INSTRUCTIONS FOR DETAILS

Application for Program Year 2022-2023

Congratulations! You are taking very important steps towards your child's successful future.

Completing this application does not guarantee placement.

**FOR NEW FAMILIES ONLY**

You do not need to fill this out if you have an application with us already or if your child is continuing for another year with our program.If you have any questions or want help filling out the application, please call us for help:715-845-2947 Fax: 715-845-0909E-Mail: nikkiparker@mccdahs.org

Si necesita esta aplicación en español, por favor haga clic aqui:

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings

PLEASE READ THE STATEMENTS BELOW CAREFULLY BEFORE SUBMITTING

REMEMBER, AN INCOMPLETE APPLICATION WILL DELAY PROCESSING-SEE INTRODUCTORY INSTRUCTIONS FOR DETAILS

FOR NEW FAMILIES ONLY

You do not need to fill this out if you have an application with us already or if your child is continuing for another year with our program.
If you have any questions or want help filling out the application, please call us for help:
715-845-2947 Fax: 715-845-0909
E-Mail: nikkiparker@mccdahs.org