Apply Online

Welcome to our online application system! We're glad you're here!
🙂

Has your family previously applied to our program?
If so, click here to update your information

If you are applying for the first time, please complete the form below.

First Name (Required)

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)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Lives with Family (Required)

Provides Financial Support (Required)

Teen Parent (Required)

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

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)

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

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)

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)

First Name (Required)

Last Name (Required)

Suffix

Birthday (Required)

Gender (Required)

Race (Required)

Hispanic (Required)

Primary Health Coverage (Required)

Other Coverage

Insurance Number

Medicaid Number

Dental Coverage

Does your child have a disability or do you have any concerns about your child's development? (Required)

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

** Already in our system? ** Click here to update an existing application

Required information is missing, see above.

Welcome to our online application system! We're glad you're here!
🙂

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings

Welcome to our online application system! We're glad you're here! 🙂

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings

Welcome to our online application system! We're glad you're here!
🙂