Parent/Guardian
First Name (Required)
Middle Name
Last Name (Required)
Nickname
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
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.
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Languages (e.g. Swahilli, Wolof)
American Sign Language
Caribbean Languages (Haitian-Creole, Patois)
East Asian (Chinese, Vietnamese, Tagalog)
English
European & Slavic Languages (e.g. German, French, Italian, Croatian, Yiddish, Portuguese, Russian)
Farsi
German
Middle Easter Language (Arabic, Hebrew, Hindi, Urdu, Bengali)
Native Central America, South America, and Mexican Language (e.g. Mixteco, Quichean)
Native North American/Alaska Native Languages
Pacific Island Languages
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Address
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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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)
Nickname
Birthday (Required)
Gender
Female
Male
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
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
English Proficiency
Little
Moderate
None
Proficient
Other Language
African Languages (e.g. Swahilli, Wolof)
American Sign Language
Caribbean Languages (Haitian-Creole, Patois)
East Asian (Chinese, Vietnamese, Tagalog)
English
European & Slavic Languages (e.g. German, French, Italian, Croatian, Yiddish, Portuguese, Russian)
Farsi
German
Middle Easter Language (Arabic, Hebrew, Hindi, Urdu, Bengali)
Native Central America, South America, and Mexican Language (e.g. Mixteco, Quichean)
Native North American/Alaska Native Languages
Pacific Island Languages
Spanish
Other Language Proficiency
Little
Moderate
None
Proficient
Family Information
Number of Parents/Guardians
One Parent Family
Two Parent Family
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
African Languages (e.g. Swahilli, Wolof)
American Sign Language
Caribbean Languages (Haitian-Creole, Patois)
East Asian (Chinese, Vietnamese, Tagalog)
English
European & Slavic Languages (e.g. German, French, Italian, Croatian, Yiddish, Portuguese, Russian)
Farsi
German
Middle Easter Language (Arabic, Hebrew, Hindi, Urdu, Bengali)
Native Central America, South America, and Mexican Language (e.g. Mixteco, Quichean)
Native North American/Alaska Native Languages
Pacific Island Languages
Spanish
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)
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Location Preferences
Which program are you applying for? (Required)
Base 2025-2026
Base PW 2025-2026
Expansion EHS 2025-2026
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
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to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Required information is missing, see above.