Please complete all information.
Parent Information-Please answer questions about education, employment, and income based on the date of the application. For teen parents, only enter "Yes" if 19 years or younger on the date of the application.
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Only complete this section if the Secondary Adult is currently living in the home, being supported by the same income and they are related to the child by blood, marriage, or adoption.

Are there other adults in the household?

Add Another Adult
For TANF, SSI, WIC, or SNAP only answer "Yes" if you are currently receiving those benefits. Proof of income and copies of awards letters will be requested.
CHILD APPLICANT INFORMATION-If your child has an IEP or IFSP in place, please place the diagnosis along with services begin and end dates in the notes section.
- Your Address - Available Locations
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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
Thank You For Your Interest in Our Program. Please attach proof of income. One of our staff members will be in contact to complete an application interview.
Required information is missing, see above.