Applications are returned to: 1618 D Ave. Anacortes WA. 98221 Feel free to deliver by mail or in person! Eligibility and enrollment are based on determined need, so please fill out your application completely and accurately! A program representative will contact you by early August with selection decisions. In order to process your attached application, we MUST have the following documents: Proof of Income Child's Immunizations Updated Physical Exam Updated Dental Exam Thank you and feel free to contact us with any questions!
Parent/Guardian
First Name (Required)
Middle Name
Last Name (Required)
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
English
Spanish
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)
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to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
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
English
Spanish
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
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
English
Spanish
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)
First Name (Required)
Middle Name
Last Name (Required)
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
English
Spanish
Primary Health Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
Doctor/Medical Home
Anacortes Family Medicine
Carol Budzik
Caroline Roeder
Catherine Mizen, MSN, ARNP
Dr. Banjanin
Dr. Cowen
Dr. Green
Dr. Lowe
Dr. Richards
Dr. Robert Kilger
Dr. Soun
Dr. Sweeney
ELMM Clinic
Ferndale Family Medicine
Fidalgo Medical Associates
Island Family Physicians
Jody Cousins
Michael C James
Mitch Markovich
Rosie(ASD)
Sea Mar Clinic
Skagit Family Health Clinic
Skagit Pediatrics
Skagit Regional Health
Skagit Valley Medical Center
Tere McCarrol
The Lion's Club
Dental Coverage
Children's Health Insurance Program (CHIP)
Combined Medicaid/CHIP
Medicaid
No Insurance
Other
Private Health Insurance
State-Only Funded Insurance
Dentist/Dental Home
Dr. Gailraitn
Dr. Hutsinger
Dr. Soun
Kulshan Pediatric Dentistry
Michael Lemme, DDS
Oak Harbor Pediatric Dentistry
Play House Dental
PlayHouse Dental
Ray Dailey
Sea Mar Dental
Sound Dentistry Anacortes
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)
Head Start 2023-2024
EHS 2023-2024
Samish EHS for children ages 0-3
ELC 2023-2024
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
Please click submit to finalize your application. We will contact you to set-up an intake appointment.
Required information is missing, see above.