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.
Parent/Guardian
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
Female
Male
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
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
Lives with Family
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Languages
American Sign Language
Arabic
Armenian
Bassa
Burmese
Cambodian
Chin
Chinese
Creole
English
Falam
Farsi
French
French-African Language
Gujarati
Hakha
Hmong
Indonesian
Japanese
Kachin
Karen
Karenni
Kayah
Kazkh
Korean
Lao
Laotion
Lo Mi
Maleyu
Marshallese
Mizo
Nepalese
Other Languages
Phillipino
Pohnpeian (Hawaii)
Polish
Portuguese
Punjabi
Pwo
Serbo-Croatian
Sgaw
Spanish
Spanish
Swahili
Tedim
Turkish
Urdu
Vietnamese
Zo Mi
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Teen Parent
Yes
No
Address
Please enter your living and mailing address. If you have an apartment or unit # please put that in the box labeled Address Line 1.
Is your family experiencing homelessness?
Yes
No
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
Additional Parent/Guardian
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?
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 Languages
American Sign Language
Arabic
Armenian
Bassa
Burmese
Cambodian
Chin
Chinese
Creole
English
Falam
Farsi
French
French-African Language
Gujarati
Hakha
Hmong
Indonesian
Japanese
Kachin
Karen
Karenni
Kayah
Kazkh
Korean
Lao
Laotion
Lo Mi
Maleyu
Marshallese
Mizo
Nepalese
Other Languages
Phillipino
Pohnpeian (Hawaii)
Polish
Portuguese
Punjabi
Pwo
Serbo-Croatian
Sgaw
Spanish
Spanish
Swahili
Tedim
Turkish
Urdu
Vietnamese
Zo Mi
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Family Information
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
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 Languages
American Sign Language
Arabic
Armenian
Bassa
Burmese
Cambodian
Chin
Chinese
Creole
English
Falam
Farsi
French
French-African Language
Gujarati
Hakha
Hmong
Indonesian
Japanese
Kachin
Karen
Karenni
Kayah
Kazkh
Korean
Lao
Laotion
Lo Mi
Maleyu
Marshallese
Mizo
Nepalese
Other Languages
Phillipino
Pohnpeian (Hawaii)
Polish
Portuguese
Punjabi
Pwo
Serbo-Croatian
Sgaw
Spanish
Spanish
Swahili
Tedim
Turkish
Urdu
Vietnamese
Zo Mi
Is another language being acquired or learned at home?
Yes
No
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)
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
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 Languages
American Sign Language
Arabic
Armenian
Bassa
Burmese
Cambodian
Chin
Chinese
Creole
English
Falam
Farsi
French
French-African Language
Gujarati
Hakha
Hmong
Indonesian
Japanese
Kachin
Karen
Karenni
Kayah
Kazkh
Korean
Lao
Laotion
Lo Mi
Maleyu
Marshallese
Mizo
Nepalese
Other Languages
Phillipino
Pohnpeian (Hawaii)
Polish
Portuguese
Punjabi
Pwo
Serbo-Croatian
Sgaw
Spanish
Spanish
Swahili
Tedim
Turkish
Urdu
Vietnamese
Zo Mi
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
Doctor/Medical Home
Access2Care
ACE-SAP Free Clinic
Allen Women's Health
Alternatives Pregnancy Center
Aplington-Parkersburg Family
Buchanan County Health Center
Cedar Valley Eye Care
Cedar Valley Family Medicine
Cedar Valley Medical Specialist
Central Rivers AEA
Childrens Wisconsin Medical
Christophel Clinic
Dan Dye OD
DHS FIP
Eastern Iowa Health Center
EyeCare Associates
Family Medicine Grundy Center
Fiat Family Medicine
Floyd County Medical Center
Guiding Start Cedar Valley
I Smile
Iowa Family Support Network
Iowa State Uni Extension & Outre
Kettman
Marengo Family Medical Clinic
McFarland Clinic Main Street
Medical Associate of BCH
Mercy Medical Center-Cedar Rapid
Mercy One Fairbank Family Med
Mercy One Family Medicine
Mercy One Jesup
Mercy One Kimball Family Med
Mercy One Pediatrics
Mercy One-Bluebell Clinic- CF
MercyOne Evansdale Family Medici
MercyOne Family Med Tripoli
MercyOne Grand Crossing Family M
MercyOne OB/GYN
New View Family Eye Care
Northeast Family Practice Center
Orchard Family Medicine
Peoples Community Health Clinic
Primary Health
Regional Family Health
Total Health of Iowa
UI Health Care
United Medical Park
Unity Point clinic family Medic
Unity Point Clinic-Dale Street
Unity Point Fam Med-Evansdale
Unity Point FM Rohlf Memoria
Unity Point-North Crossing
Unity Point-Vinton
UnityPoint Eldora
UnityPoint Fam Med Logan Ave
UnityPoint Family Clinic Conrad
Unitypoint Oelwein
UnityPoint-Hiawatha
UnityPointClinic Prairie Parkway
University of Iowa Childrens Hos
Waverly Health Center
Waypoint Services
WIC/Operation Threshold
Wolfe Eye Clinic
YWCA
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dental Coverage Number
Dentist/Dental Home
All Smiles
American Dental A. Reinbeck
Anderson & Floyd Dentistry
Balster Pediatric Dentistry
Berryman Family Dentistry
Brenden & Brenden DDS
Cedar Brook Dental Group
Cedar Rapids Pediatric Dentistry
Cedar Valley Dental Associates
Cedar Valley Pediatric
Cedarloo Dental
Childrens Wisconsin Dental
Childrens Wisconsin Dental Cente
Clear Lake Pediatric Dentistry
Corridor Kids Pediatric Dentistr
Crossroads Dental
David Bottke, DDS
Denver Family Dental
Dr. Jones Dentistry
Eastern Iowa Health Center-Denta
Edwards.Smith Family Dentistry
Evansdale Family Dentistry (Wern
Gentle Dental PC
Greenhill Family Dental
Grundy Center Family Denistry
Hintz Family Dentistry
Hudson Family Dentistry
Iowa Pediatric Dental Center
Kegler, Kegler & Arend Family De
Kimball & Beecher
Kimball & Beecher
Main Stret Dental
Manchester Dental
Marquette University School of D
Midwest Dental - Waverly
Midwest Dental Cedar Falls
Northeast Iowa Pedia Dentistry
Oelwein Dental Associates
Only Kids Dentistry
Parkersburg Family Dental
Peoples (PCHC)-Dental Clinic
Peoples Clinic-Butler County
Peoria County Health Department
Pipho Family Dentistry
Primary Health Care Dental
Ridgeway Dental
Rockdale Dental Center
Scott Hansen
Smiles in Motion
Southridge Dental
St. Lukes Dental
Troutman
University Of Iowa Dental Clinic
Valley Park Family Dental PC
Walker Dental
Waterloo Dental Associates
Waterloo Pediatric Dentistry
West First Dental
Whittemore Family Dentistry
Zachary Stecklein
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Infants/Toddlers/Pregnant Moms for 2024-2025
Expectant Mothers and Children 0 - 35 months old
Preschool for 2024-2025
Children Ages 3-5 years old
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
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.