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Thank you for your interest in Bear River Head Start Programs. This application form is for NEW families. If you have had a child in our Head Start Program in the past or you have applied in previous years, please call the ERSEA office at 435-755-0081 Ext 321, 410, or 325 *Make sure to use correct spelling of names as shown on official documents. *The more information we have the quicker your application process will be. Ex: including income and birth documents *If you were working with a staff member with applying, please include their name in the notes section available. *You may include housing costs if you are over income (IE Mortage statements, Rental Statements and utility statements)

***Please provide a phone number that is able to receive text messages and/or an email address.***

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

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)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

Temporary Living Arrangement Question: Please mark YES if any of the following apply to your family situation. *Do you currently share a residence? *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

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

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)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Highest Grade Completed (Required)

Employment Status

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Teen Parent

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?

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)

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

Race (Required)

Hispanic (Required)

Lives with Family (Required)

English Proficiency (Required)

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Doctor/Medical Home

Dentist/Dental Home

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?

Learn about BRHS?

Potty Trained

Behavior Concerns

Developmental Concerns

Health Concerns

Dietary Needs

Referral Agency

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 completing the pre-application. Someone from our office will contact you to set up an intake appointment. Please click submit to finalize your pre-application.

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