Apply Online

WELCOME! Please complete this initial application to apply for enrollment. After the application is submitted, a member of our enrollment team will contact you for additional required information and to discuss options for services.

Please enter the primary legal guardian of the child applicant. For teen parents, only enter "Yes" if 19 years or younger on the date of the application.

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

Highest Grade Completed

Employment Status

Child's Relationship

Lives with Family

Teen Parent

Please enter your living and mailing address. If you have an apartment or unit # please put that in the box labeled Address Line 2.

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

Only complete this section if the Secondary Adult is currently living in the home, being supported by the same income, and related blood marriage or adoption.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

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

Child's Relationship

Please enter the following information that applies to your family situation. For TANF, SSI, WIC, or SNAP, only answer "Yes" if you are currently receiving benefits. Proof of Income for previous 12 months and copies of award letters will be requested.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

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 enter the following information on the child you would like to enroll.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Primary Health 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

To complete your online application process please select "I am not a robot" and continue to attach the needed documents for your application.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings