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Parent/Guardian
First Name (Required)
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Email Address (Required)
Confirm Email Address
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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
African-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
Doctorate
General Education Diploma
Grade 1
Grade 10
Grade 11
Grade 12
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 9 or less
High School Graduate
Master's Degree
No Education
Some College
Training Certificate
Employment Status
Active Military
Full-time & Training
Full-time (35 hours/week or more)
In Training
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
School
Seasonally Employed
Self Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
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
African-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
Doctorate
General Education Diploma
Grade 1
Grade 10
Grade 11
Grade 12
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 9 or less
High School Graduate
Master's Degree
No Education
Some College
Training Certificate
Employment Status
Active Military
Full-time & Training
Full-time (35 hours/week or more)
In Training
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
School
Seasonally Employed
Self Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Family Information
~Child's shot record~ ~Child's birth certificate~ ~proof of family income (ie: W-2, income tax return, letter from employer)~ These documents are needed and can be emailed to: meyer@caasiouxland.org
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
African-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Number in Household
Number in Family
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)
First Name (Required)
Middle Name
Last Name (Required)
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
African-Swahili, Wolof, Oromo, Somali
American Sign Language
Amharic
Arabic
Caribbean-Haitian, Creole, Patois
Chuukese
Dari
Dinka
East Asian-Vietnamese, Chinese, Tagalog
English
European & Slavic-German, French, Russian
Farsi
French
Hmong
Krahn
Lao
Mam
Middle Eastern & South Asian-Hindi
Nara
Native Central American-Quichean, Mixteco
Native North American & Alaska Native
Oromo
Other-Please specify in notes
Pacific Island-Fijian, Tongan, Polynesian
Pashto
Pohnpeian
Portuguese
Somali
Spanish
Swahili
Tagalog
Tajik
Tigrinya
Vietnamese
Wolof
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Doctor/Medical Home
Able Kids
AFANA Najdawi, SUHAIR
Agboro-Idahosa, Ejiro MD
Anderson, Richard C. DO
ANDRAWIS, AMIR
Andrew Geha
Ansari Nadia MD
AVERA MCKENNAN HOSPITAL
Avera Medical Group Pediatric Sp
BARTO, EILEEN
Bechtold, Nick MD
BECK, PATRICK MD
Beecher, Scott
Bergen Mercy Maternity Center
BERGIN, NADINE
Best, Jodi ARNP
BOYS TOWN NATIONAL RESEARCH HOSP
Boys Town Pediatric Hearing Clin
BRENNER, MICHAEL MD
BRENNER, NITYA MD
BRODERSON, JEREMY DR
BRODKEY, DANIEL DR
BRUENING EYE SPECIALISTS
Bunch, Bonnie MD
Burger, Stephanie MD
BURGESS FAMILY CLINIC
CALDWELL SUSAN MD
Carl T Curtis Health Center
CHILD HEALTH SPECIALTY CLINIC
Children's Hospital Omaha
Clausen, Jessica LISW, MSW
CNOS
COFFIN, DR.
CRITTENTON CENTER
Daffer, Michelle MD
Dakota County Health Dept.
Dakota Dunes Surgery Center
Dannenbring, Amanda MD
DANNER, KRISTINE T
Dermatology Specialists of Omaha
DONOVAN, JOHN DR. UROLOGY CLINIC
Dunes Dermatology
DUNES EYE CONSULTANTS
Dunes Surgical Hospital
EAR NOSE & THROAT CONSULTANTS
EARLEYWINE, MOLLY
Eggers, Matt MD
Ensz. David, MD
ENT Morningside CLinic
ENT SPECIALISTS, PC
EXACT EYE CARE
EYE ASSOCIATES OF SIOUXLAND
EYE MART
EyeMart Express
FALDMO, DAVID, PA
Family Med Center-Div Of SMEF
FAMILY PRACTICE ASSOCIATES
FERGUSON, STEVE, OD
Fett, Janett
FHC Dakota Dunes
FHC Indian Hills
FHC Morningside
FHC Northside
FHC South Sioux City
Fiddelke, Brooke ARNP
First Eye Associates, PC
Floyd Valley Clinics
FMC UnityPoint-SGT BLUFF
Ford, James hematoloist
Ford, Reason A MD
Galli, Janice MD
Geha Andrew
Gillette, Dan MD
Granger, Jeremy MD
Granger, Sandra MD
GUERDET, RANDY
GUPTA, ASHUTOSH MD
HALBUR, GREG MD
Hanger Prosthetics and Orthotics
Harder, Michael DO
HASLEY, BRIAN MD
HATTEN, GARY
Hatten, Michael MD
Hawk-i
HEAD START
Heartland Chiropractic
Heaton, Julia MD
Holtz, Melissa N. MD
Iowa Department of Public Health
Iowa EHDI Director | Bureau of F
Iowa ENT & Sinus Surgical Center
Jacobs, Chris ARNP
JENNINGS, MICHAEL MD
JOHNSON LEAH
Johnson, Julie A MD
JOYCE, STEVEN MD
Judy Turner
KELLOGG, JEFF MD
Kelly Bean ARNP
Kenny, Thomas
Kincaid, David
KINGSLEY MERCY MEDICAL CLINIC
KORVER EYECARE CENTER
Kramer, Bruce PA
Krause, Lori PA
Kurth, Joe MD
La Leche League of Siouxland
LAFLEUR, SHAUNA L MD
Le Mars Eye Care
Lee, Delna
Lefeber, Tyler OD
Lewin, Cindy
LifeScape- AbleKids
LONGVAL, HEATHER MD
Lorenz, Aimee DR.
Losee, Jason DO
Lund Melanie ARNP
Macy Carl T Curtis Medical Cente
Manley Obbink Chiropractic
MAPLE VALLEY MERCY MED. CLINIC
MARINO, FRANK DR.
Mayo Clinic
McCarthy, Greg
McCullough, Collette ARNP
MCINERNEY, ELIZABETH
McNaughton, Lee
Meng, Alice MD
MercyOne Anthon Family Medicine
MercyOne Correctionville Fam. Me
Mercyone Dakota Dunes Laboratori
MercyOne Singing Hills Fam. Med.
MercyOne Siouxland Medical Cente
MercyOne Siouxland Occupational
MercyOne South Sioux Fam. Med.
Meylor Chiropractic
MIDLANDS CLINIC PC
Mijangos, Sergio G, OD
Mitchell, Terry
MONONA COUNTY HEALTH DEPARTMENT
Moreno Kathy RDH, SDHD I-smile
Morris, Joseph MD
MutiCare Health Clinic
NAJDAWI, EYAD MD.
NEEDELMAN, HOWARD MD
Nelson, Maureen OD
Nemecheck, Craig Dr.
NORTHWEST AREA EDUCATION AGENCY
Olive, Young MD
Olson, Alisa M
Onawa Family Medical Clinic PC
OPHEIM KATHRYN MD
Other- Add Provider Manually
OUT of AREA PROVIDER
OUTPOST OPTICAL
Padgett April RDH SDHD I-smile
PETERSON, PAUL DO
PICK, ANN
Pick, Tracy ARNP
PLANNED PARENTHOOD
PONCA MERCY CLINIC
Powell, Sarah
Prairie Pediatrics-Northside
Pratt, Elizabeth
Pratt, Thomas O.D.
Promise Community Health Center
Pruett, Ashton ARNP
Quitline Iowa
Rabbitt Daniel Dr OD
REHAN, ANN MD
RENNEE SWEERS
Rief Elks, Amy DO
Rife, Lauren ARNP
RIVERS EDGE OPTICAL
ROBISON, BRYCE MD
Roge, Carol MD
Rosecrance Jackson Centers
ROSECRANCE JACKSON RECOVERY
ROSENKRANS, KURT MD
ROSSITER & DEMAY LLP
Rudloff Ryan OD
Rundquist, Rex
RUSCH, JAMES A. PAC
Ryder, Kelly MD
Sanford Children's Specialty Cli
Sanford Health Dakota Dunes Cli
Sanford Sheldon Clinic
Santee Health and Wellness Cente
SCHC
SCHC of Nebraska
Schenk Nancy MD
Schol, Cindy ARNP
Schryver, Thomas MD
SERGEANT BLUFF EYECARE
Shopko Opt.
Shriners Hospitals for Children
SIOUXLAND DISTRICT HEALTH DEPT
Siouxland Family Medicine Center
Siouxland Mental Health
SIOUXLAND OB/GYN
SIOUXLAND PODIATRY ASSOCIATES
SIOUXLAND UROLOGY ASSOCIATES
SIOUXLAND WOMENS HEALTH CARE
SMEF Siouxland Medical Ed. Fnd
Sorensen, Susan ARNP
SOUTHERN HILLS EYE CARE
Spartz-Kolbo, Angela OD
St Lukes-Unity Point Health
Surber Holli, ANRP
Target Optical
Todt, Dorothy MD
Tri State Specialists
Tri-State Physicians and PT
Troia, Sebastian
Twelve Clans Unity Hospital
UHL, BENJAMIN ALAN OD
UNGER MICHAEL PA
Unity Point Rehabilitation
UnityPoint Clinic Marketplace
Unitypoint Clinic Maternal Fetal
UNITYPOINT PEDIATRICS
UnityPoint Sunnybrook Clinic
UNIVERSITY OF IOWA HOSPITAL
UNIVERSITY OF NE MED CENTER
VANDE VEGTE SHARON MD
Vision Care Clinic
Vision Care Clinic
Vision Care Clinic of Moville
Vision Source
VOGEL, SHANE
WADZINSKI EYE CLINIC
WAGNER DAVID, ENT
WALDING, REBECCA ARNP
Walmart vision center
WALTZ, KRISTI MD
Weber Jacob OD
Webner Stacie, ARNP
Weese, James PA
Welch, David PA-C
WENTE, THOMAS J. DR.
WESTERN IOWA TECH COMMUNITY COLL
WIC
Winnebago Dental Clinic
WOLFF CYNTHIA MD
Womens and Childrens Center
Wright, Rhonda
Wurth Rachel
Dentist/Dental Home
AITKEN Joseph DDS
Anzalone, Lindsay Dr.
Aspen Dental
BALLER, RYAN DDS
BARR DOUGLAS DDS
Bechtold Karla DDS
BOKEMPER RICHARD DDS
BURHOOP CRAIG DDS
BURSICK BRIAN DDS
BUTTERMORE JAMES DDS
Canada Dr Ryan
Carl T Curtis Health Center
Children's Dentist
CHILDRENS DENTAL SIOUX FALLS
CLARK THOMAS DDS
CORK DONALD DDS
CORRECTIONVILLE DENTAL CLINIC
Dannenbring Zach Dr
DESTIGTER TIM DDS
DOHRMAN RICHARD DDS
DUNES DENTAL 4 KIDS
ELITE DENTISTRY
Embrace Dunes Dentistry
FAMILY 1ST DENTAL
FAMILY 1ST DENTAL S Sioux
Family Dental Care of Sioux City
Family Dental Sunnybrook
Fedyszyn, Daniel DDS
FRANK SHAMAYNE
Frein, Dawn DDS
Giese, Laura DDS
HALBUR JOANNA DDS
HANSEN GREGORY G DDS
HAUSMAN-MILLER, BRENDA
Hemmingsen, Jeff
Howenstein, Jeff
Huber, Ashley
Husen, Renee DDS
ISmile
JENSEN, BRANDON DDS
Kaler, Daniel DDS
KAVA RICK DDS
KEHM DAVID DDS
KIPLE CHARLES DDS
KNOPIK TOD DDS
KOELLING SARA DDS
KOTIL DARREN DDS
KULAWIK MITCHELL DDS
KURTH, JADA DDS
LEWIS WAYNE DDS
LILLY Family Dentistry, PC
Lohr, Julie
Macy Carl T Curtis Medical Cente
McCarthy-Clifford Dr. DDS
McGuire, Matthew DDS
MCKENNA, RYAN
MENKE, TB DR
Moreno Kathy RDH, SDHD I-smile
MORNINGSIDE DENTAL CLINIC
MUNCH ELIZABETH DDS
Nguyen, Phuong DDS
NIELSEN, BETHANY
NOBLE DAVID DDS
NORTH SIOUX DENTAL CLINIC
ONAWA FAMILY DENTISTRY
ORAL SURGERY AND IMPLANT SPECIAL
Other- Add Provider Manually
OUT of AREA PROVIDER
Padgett April RDH SDHD I-smile
PATERA FAMILY DENTISTRY
PAULSON, JILL DDS
PRINCE DONA DDS
Promise Community Health Center
Reeves, Kate DDS
REINKING JEFF DDS
RIZK FRED DDS
SALMONS IVAN DDS
SCHC DENTAL
SGT BLUFF DENTAL
Sgt. Bluff Smiles
SHAW LOWELL DDS
Sloan Family Dnetistry
STEVENS MINDY
Summit Dental
Summit Dental Health S. Sioux
SUNNYBROOK DENTAL
The Dentist at Lakeport
THE DENTIST DEPOT
TIEDEMAN THOMAS DDS
TRI-STATE DENTAL CARE
Uhl, Allison DDS
UNIVERSITY OF IOWA HOSPITAL
UNIVERSITY OF NE MED CENTER
WALTON SHAWN DDS
Welch, John DDS
WHEATLEY, MICHAEL DDS, PC
WHEELOCK DOUGLAS DDS
Whispering Creek Dental Clinic
WHITING DANNY DDS
Winnebago Dental Clinic
WISNER , Amber DDS
Does your child have a disability or do you have any concerns about your child's development?
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No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Infant Toddler classroom
1st Location Preference
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2nd Location Preference
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- Your Address
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Additional Applicant
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Add Another Applicant
Required information is missing, see above.