The following is an Interest form for Little People's Head Start.
Parent/Guardian
Please answer questions about education, employment and income based on the date of the application. For teen parents, only enter 'Yes' if 19 years or younger on the date of application.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
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.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Chinese
English
Other
Spanish
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Address
Is your family experiencing homelessness?
Yes
No
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
Additional Parent/Guardian
Only complete this section if the Secondary Adult is currently living in the home, being supported by the same income and related blood marriage or adoption.
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.
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Chinese
English
Other
Spanish
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Other Relative
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Family Information
For TANF, SSI, WIC or SNAP only answer 'Yes' if you are currently receiving those benefits. Proof of Income and copies of awards letters will be requested.
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
American Sign Language
Chinese
English
Other
Spanish
Vietnamese
Is another language being acquired or learned at home?
Yes
No
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?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Is your family receiving services from WIC?
Yes
No
WIC ID (if applicable)
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
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
Emergency Contacts
Add Emergency Contact
Child (Applicant)
If your child has an IEP or IFSP, please list the diagnosis along with services begin and end dates in the notes section below.
First Name (Required)
Middle Name
Last Name (Required)
Suffix
Nickname
Birthday (Required)
Gender
Female
Male
Race
American Indian or Alaska Native
Asian
Black or African American
Multi-racial/Biracial
Native Hawaiian/Other Pacific Islander
Other
Unspecified
White
Hispanic
Yes
No
English Proficiency
Little
Moderate
None
Proficient
Other Language
American Sign Language
Chinese
English
Other
Spanish
Vietnamese
Other Language Proficiency
Little
Moderate
None
Proficient
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Other Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Insurance Number
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Medicaid Number
Doctor/Medical Home
Amy Hemsley NP
Delta Family Medicine
Delta Family Services
Dixie Pediatrics
Dr Willferd
Dr. Amy Barney
Dr. Benjamin Willford DO
Dr. Gary Seigel
Dr. Ha Vu MD
Dr. Nancy Baker, D.O.
Dr. Nasir Uddin MD
Dr. Pratt
Dr. Rocky Jones
Dr. Strumello
Dr. Suzette Axelgard APRN
Dr.Dallan Ormond
Kent Robertson DO
Nancy Plaskett
Newe Clinic
Office Of Vital Records
Tyler Robertson
Univeristy of Utah Health Care
WIC
William Bee Ririe Clinic
WPC Health Nurse
WPC School District
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dental Coverage Number
Dentist/Dental Home
Any Day Dental
Cedar Pediatric Dentistry
Delta Family Services
Desert Kids Dental
Dr Sena
Dr. Albeth
Dr. Prada
Dr. Sullivan
Dr. VanTassell
Elko Dental Specialists
Family Dental
Miles for Smiles
Pediatric Dental Care Associates
Primary Dental
Ronald McDonald Dental Van
Springville Dentistry
St. George Kids Dental
Steven Klomp, D.D.S.
Todd Wilkin, D.D.S.
university of Nevada
UNLV School of Dental Medicine
Wendover Dental
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
Infants/Toddlers for 2023-2024
Birth - 35 months old
Preschool for 2022-2023 School Year
Children Ages 3-5 years old
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
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
Are there other children in the family?
Add a Sibling
You will receive an email confirmation once the application is submitted. We will contact you to schedule an appointment in order to complete the registration process. You are responsible for updating contact information if it changes. We will only use the numbers and addresses submitted to notify you of your child's status.
Required information is missing, see above.