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Thank you for taking the time to fill out our Early Head Start application! We are looking forward to getting to know more about your child and family, our Early Head Start Program is designed for prenatal mothers, and children 6 weeks to 3 Years. This application has multiple parts, please make sure you fill out the initial application, attach any necessary documents that would help us better serve your family and child and fill out our final questionnaire at the end. If you have any questions or need assistance please call Sonely Rivera at 518-292-5510 and choose option 6.

Please Complete each section

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)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency (Required)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Lives with Family (Required)

Provides Financial Support (Required)

Teen Parent (Required)

How did you hear about us (Required)

Early Intervention

CPS

Prevention

Healthy Sch'dy Families

Health Homes

Young Parents United

Other

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)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender (Required)

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)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency (Required)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Lives with Family (Required)

Provides Financial Support (Required)

Teen Parent (Required)

Are there other adults in the household?

Add Another Adult

Number of Parents/Guardians (Required)

Relationship to Participant(s) (Required)

Primary Language at Home (Required)

Is another language being acquired or learned at home? (Required)

Number in Household (Required)

Number in Family (Required)

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? (Required)

Is at least one parent/guardian a veteran of the United States military? (Required)

Add Emergency Contact

*If you are a prenatal mother applying for our home based program option- please fill out this section accordingly-in the First Name field please fill in as "unborn", in the Last Name field please fill in as the last name you plan on giving your child and for the birth date please fill in as the expected due date of your child.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

English Proficiency (Required)

Other Language (Required)

Other Language Proficiency (Required)

Primary Health Coverage (Required)

Other 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?

Early Intervention

CPS

Prevention

Healthy Sch'dy Families

Health Homes

Young Parents United

Other

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

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