Apply Online

Online Application Instructions: Fill out all required fields (those with that say "Required"). Fill out as much as possible the optional fields (the more information we have the better our ability to serve you). Make sure to hit the submit button at the end of the application. By submitting this application online you are certifying that the information given on this application is correct to the best of your knowledge.

First Name (Required)

Last Name (Required)

Nickname

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

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)

Last Name (Required)

Suffix

Nickname

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

Lives with Family

Provides Financial Support

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

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 fill out the following information on the child you wish to enroll with us. Please note that Medicaid means MaineCare.

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

Insurance Number

Medicaid Number

Dental Coverage

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

The following information is required to process your application. Not supplying the required documentation will delay processing.

• Copy of Child's Official Birth Certificate

• Copy of Child’s most recent immunization record (child must be up-to-date on all immunizations in order to be enrolled in our program per Maine State Law)

• Proof of Income: SNAP, TANF, SSI, or if you do not receive those benefits, please send W-2 or 1040 Tax Form

• If applying for a foster child, please send proof of verification of guardianship

• If unhoused, please reach out to Jesse Westman at jwestman@penquis.org / 973-3516 or Kelley Graffam at kgraffam@penquis.org / 973-3567

You can email those documents to jwestman@penquis.org or you can mail them to Penquis Early Head Start/Head Start, PO Box 1162, Bangor, ME 04402-1162. *If neither of these options work, please contact Jesse Westman at 973-3516 and we will figure out another way.

In accordance with Federal Regulations, Penquis does not discriminate in access to or the provision of its services.

By submitting this application online, you are certifying that this information is true. If any part is false, your participation in this agency’s programs may be terminated and may be subject to legal action. You, also understand that the information in this application will be held in strict confidence within the agency and is accessible to you during normal business hours.

Thank you for your interest in Penquis Head Start / Early Head Start. We will be in touch soon to let you know the status of your application.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings