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Please fill out this form to apply for the Early Head Start program. After completing the application you will be directed to a scheduling page to schedule your 15 minute Eligibility meeting to complete the application process. ***If your child is older than 3 years of age(age 3-5), they will not qualify for our program, please apply for Early Learning Essentials Head Start by going to their website at: www.mountainlandheadstart.org/enrollment.cfm

Please fill out this section with the information of the Primary adult. Fill out as much of the information as possible including; 1. Your relationship to the applicant 2. If you have custody of the applicant 3. If you live with the applicant 4. If you provide financially for the applicant

First Name (Required)

Middle Name

Last Name (Required)

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.

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

The Kids On The Move Early Head Start Program serves Utah County residents. You will be asked about your housing situation later in the application process.

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

This section covers the information for the second parent -or- if there is another guardian who is: 1. Related to the child you're applying for through blood, marriage, or adoption. and 2. Supported by the income and 3. Resides in the home

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

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.

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

Are there other adults in the household?

Add Another Adult

Please refer to the following when answering questions in this section: Number in Household = Number of people living in your home Number in Family = Number of people actually supported by your income, and related to applicant by blood, marriage, and/or adoption Gross Actual Income = You can estimate here, however, proof of actual income will be required before acceptance to the program.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

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?

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

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?

Please completely fill out the following information for the child you are applying for.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Medicaid Eligibility

Doctor/Medical Home

Dental Coverage

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

Thank you for your interest in our program. Please continue on to schedule a 15 minute appointment with the Enrollment manager to complete your application. You will be required to bring proof of income, proof of age, and current immunizations and well child exams for you child to this meeting. Please feel free to call Barbara Quintana if you have any question at 801-709-0244 or 801-221-9930 ext 153 or by email bquintana@kotm.org.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings