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Federal and State regulations require a formal application and certification for child development services. The Agency must verify and certify family eligibility prior to beginning services. This application will initiate the verification procedure, after completing and submitting the form a staff member will contact you and assist you in completing the application. Once the process is completed and the application has been reviewed you will receive written notification of your results.

First Name (Required)

Last Name (Required)

Suffix

Birthday (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

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.

Child's Relationship

Teen Parent

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

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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)

Are there other adults in the household?

Add Another Adult

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

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

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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

In advance of meeting with a staff member here is a list of required documents; Financial Documents, immunization information, proof of residence and birth certificates to all in family members under 18 years old. If you have access to a computer/printer or have a scan application on your mobile phone you can request to receive an email address to electronically submit your documents.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Child (Applicant)

Location Preferences

Additional Applicant

Siblings