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Welcome to UAMS Early Head Start, please complete all fields of the application in order to establish eligibility. Note: Child must be under three years to enroll. In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs)

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

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.

Race (Required)

Hispanic (Required)

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Must be a resident of Pulaski County

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

Please ONLY complete this section for the Secondary Adult, if they are living in the home with the applying child. If you are single you may skip this section.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

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.

Race (Required)

Hispanic (Required)

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

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

Number in Family

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)

WIC ID (if applicable)

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

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender (Required)

SSN

Race (Required)

Hispanic (Required)

Other Language

Other Language Proficiency

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?

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 your interest in our program, please click the submit button to finalize your application. To complete your application we will need your CHILD'S BIRTH CERTIFICATE AND PROOF OF INCOME (W-2 form, 1040 form, TANF form, SSI letter, etc....). There are 3 ways you can get this information to us. 1. You can attach documents by following the instructions on the next page. 2. You can email them to reichardhellenr@uams.edu 3. You can bring them to our main office at 8901 Kanis Road, Little Rock, AR. Please make sure we get these documents to us as soon as possible. YOUR APPLICATION IS NOT COMPLETE WITHOUT THESE DOCUMENTS. When a spot becomes available for your child, we will notify you. If you move or change your phone number, please call us to update your information. Our number is 501-570-5000. If you are accepted into our program, you will be called to come in and complete the enrollment process. You will need to bring the following documents at the time of your appointment: Child's shot record, current physical & dental exam.

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