Apply Online

Thank you for using our online application portal. This will allow Learning Together to better know and serve your child and family. It also allows us to track demographics as well as other valuable indicators that are required for resource identification. All information gathered is confidential, as Learning Together follows all HIPPA rules and regulations.

COMPLETE THIS SECTION FOR PRIMARY ADULT IN YOUR HOME

First Name (Required)

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

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

Custody

Teen Parent

If Teen Parent, Subsidized?

PLEASE PROVIDE ADDRESS WHERE YOU ARE CURRENTLY LIVING

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

LIST ALL ADULTS LIVING IN THE HOME

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Suffix

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

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Teen Parent

If Teen Parent, Subsidized?

Are there other adults in the household?

Add Another Adult

PLEASE PROVIDE INFORMATION ABOUT YOUR HOUSEHOLD. RELATIONSHIP TO PARTICIPANT WILL BE YOUR RELATIONSHIP WITH WHOM YOU ARE ENROLLING.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Household

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 PROVIDE INFORMATION ABOUT THE CHILD YOU ARE ENROLLING

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Medicaid Eligibility

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

Thank you once again for your interest in Learning Together. Your enrollment application will be reviewed and someone will follow up with you in the near future.

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