We are so happy that you are interested in enrolling your child with Middle Kentucky Head Start for the 2024 - 2025 school year! This is our Temporary Enrollment Application. This application will let the Head Start Family Service Worker in your area know you are interested in enrolling in our program. Please complete all spaces on this form so that the Family Service Worker can begin your enrollment in our program!
Parent/Guardian
Please complete ALL fields so we have the correct information when we contact you!
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 (Required)
Opt In for Text Messages
Yes
No
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.
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Address
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
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.
Lives with Family
Yes
No
Custody
Yes
No
Other Adults
Are there other adults in the household?
Add Another Adult
Family Information
It is important that everyone living in the household is counted so that income can be calculated accurately.
Number of Parents/Guardians
One Parent Family
Two Parent Family
Primary Language at Home
American Sign Language
English
Spanish
Number in Household
Gross Annual Income
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 tell us about your child!
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
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)
Preschool for 2024 - 2025 School Year
Free Preschool for Children Ages 3 - 5
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
Thank you for taking your time to complete our Temporary Enrollment Application. A Family Service Worker will contact you as soon as they review your application. You are welcome to call the Family Service Worker in your area at any time to check on the status of your application or to make an appointment to complete the full enrollment packet and turn in required documents. Breathitt County Head Start Centers- 606-666-8585, Lee County Head Start - 606-464-3140 or 3329 option 2, Wolfe County Head Start - 606-668-7879 or 7111 option 1. Middle Kentucky Head Start is excited to get to know your family!
Required information is missing, see above.