Apply Online

Thank you for your interest in Pocatello/Chubbuck SD25 Head Start. This application form is for NEW families who meet the income guidelines indicated in the chart above. *Make sure to use correct spelling of names as shown on official documents. ** If your family has EVER APPLIED with the Pocatello/Chubbuck Head Start, please DO NOT complete the online application. Call 208-233-6606 to update your information and complete an application.

For those who meet the income guidelines indicated in the chart above, please provide the information for the primary adult with which Head Start will communicate. This adult must have primary guardianship of the applicant child. Creating a duplicate application may create a delay in the application process. <<>>

First Name (Required)

Middle Name

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 (Required)

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 and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Experiencing Homelessness Question: Please mark YES if any of the following apply to your family situation. * Do you currently share a residence and are not on the lease or paying rent? *Live in a shelter, motel/hotel, car, park, or campground? * Is your living arrangement temporary? * Are any of these due to loss of housing or inability to afford housing?

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

Secondary adults are considered adults who live in the household and are related to the applicant child through blood, marriage or adoption. Other adults may be added as emergency contacts if desired.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

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

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 and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Provides Financial Support

Additional paperwork may be needed at time of application.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Family

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 from WIC?

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Birthday (Required)

Gender

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Medicaid Number

Doctor/Medical Home

Dentist/Dental Home

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

Once you have completed your PRE-application we will be in touch with you to complete and finalize your application. If you have not heard from within three weeks time, please call us at 208-233-6606. Please click Save and Continue to finalize your PRE-application. Documents may be loaded after submission.

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings