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Welcome to Mountain States Early Head Start, a free child development and parenting support program for families with infants and toddlers and pregnant women. We provide services in Bonner, Kootenai, and Shoshone counties.

Please complete the application with as much information as possible. If you are applying as a pregnant participant, complete the Child (Applicant) section with first name as "Baby" and Birthday as your due date. Any information you share with us will be protected and you and your family will be informed if and when information needs to be share with authorized professionals. Thank you for your time. We look forward to working with you and your family.

First Name (Required)

Last Name (Required)

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.

Employment Status

Child's Relationship

Please complete the address information below.

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)

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.

Employment Status

Child's Relationship

Please complete the following family information, including emergency contacts.

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 under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

Please complete information for each child under the age of 3 applying for services. **If this is a pregnancy, complete the Child (Applicant) section with first name as "Baby" and Birthday as your due date.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Primary Health Coverage

Other Coverage

Doctor/Medical Home

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?

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 for taking the time to complete the application. We look forward to providing helpful support and education for you and your family.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings