Apply Online

**For NEW families only. Returning families please call the center for an appointment.** Thank you for your interest in the Delaware County Intermediate Unit’s Early Head Start program! Please enter all information accurately and to the best of your knowledge on the subsequent pages. The information you will need to complete the online registration is: - Name and birth date of every person in the house. - Address and phone number. - Email address for primary adult, and if applicable, secondary adult. - Health Insurance card for insurance numbers. - Name and phone number for doctor and dentist. Please have this information with you to complete the online application. If there is a particular site you would like your child to attend, you will have the option to specify which site you prefer. You MUST complete the application at one time. Once you have completed and submitted your application, a confirmation email will be sent to the email address you provided. If you do not have an email address, you will need to create one prior to continuing.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

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 (Required)

Opt In for Text Messages

Home Phone (Required)

Work Phone (Required)

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 (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent (Required)

If Teen Parent, Subsidized? (Required)

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 (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

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

Lives with Family

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Please enter all of the information below accurately. The following are some helpful hints when completing this information: Parental Status: - Single Parent – if only one of the child’s parents live in the house - Two Parent – if both of the child’s parents live in the same house - Grandparent – if grandparent(s) have guardianship/custody of child All other information is completed with drop-down answers.

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home?

Gross Annual Income (Required)

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

WIC ID (if applicable) (Required)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

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 enter all required information. The child you are registering for Early Head Start is considered the Applicant. The medical coverage information will be located on the child’s health insurance card.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage (Required)

Other Coverage

Insurance Number (Required)

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home (Required)

Dental Coverage (Required)

Dental Coverage Number (Required)

Dentist/Dental Home (Required)

Does your child have a disability or do you have any concerns about your child's development? (Required)

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

Please check your email for a confirmation of your application submission. Your application will be forwarded to the appropriate staff and you will hear from us shortly to set an appointment to bring required documents. To further prepare for your appointment, please gather the following documents. These documents will be required to complete your registration. Without the following, your registration will be considered incomplete. The required documents are: - Birth certificates for all children in the house. - Proof of income. (If paid bi-weekly, you need to bring two (2) consecutive paystubs. If paid weekly, you need to bring four (4) consecutive paystubs. You can also bring your W-2, 1040 or 1090 from the previous year. If you receive public assistance, child support, SSI or are applying for a foster child, please bring the print-out indicating the amount you receive monthly) - Physical – must be current within one year. - Up-to-date immunization records (shot records). - Dental – must be current within six months. - Health Insurance card. - Allergy forms (If your child has any allergies, please make sure to bring completed allergy forms to your appointment). - Picture ID for all adults in the house. - Recent utility bill. - WIC ID (If you are receiving WIC services). - CCIS letter or waitlist letter (if receiving CCIS). Again, we look forward to working with your family! Thank you for partnering with us!

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant