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2023/2024 School Year Thank you for your interest in the Iowa Tribe of Oklahoma Early Head Start and Child Care Program. In order for us to determine eligibility, all information needs to be filled in to the best of your ability and the information listed below needs to be turned in. Information needed when completing an application is: completed application copy of child/parent CDIB card, child's state issued birth certificate or hospital, child's up-to-date immunizations, Insurance card income verification (recent income for a month period, income Tax 1040 or W-2, or public assistance Letter (TANF, SNAP or SSI),

Head of Household

First Name (Required)

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.

SSN

Race

Hispanic

English Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

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)

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

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Are there other adults in the household?

Add Another Adult

Please provide information when filling out application. Program will also need income verification before processing the application.

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?

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

Please ensure all information is provided when filling out the application

First Name (Required)

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

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

Thank you for filling out the application. Please submit the application to finalize for submission. You will be contacted within two weeks.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings