Parent/Guardian
Please complete the questions below. Check the Teen Parent box if you are under the age of 18. Check the Teen Parent subsidized box if you are participating in a program designed specifically for teen parents.
First Name (Required)
Last Name (Required)
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
Home Phone
Work Phone
Ext.
Teen Parent
Yes
No
If Teen Parent, Subsidized?
Yes
No
Address
Please include apartment/building/lot number, direction (Southeast, Northeast, etc) if applicable.
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
Family Information
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
Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?
Yes
No
Child (Applicant)
***FOR WOODSON PARK ONLY - In the section below, Is there anything else you would like for us to know about your child? Please add the name of sibling(s) already participating in the WOODSON PARK program.***
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Medicaid Eligibility
Not Eligible
On Medicaid
Potentially Eligible
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)
2019-2020 Early Head Start
No Cost Early Learning 0 - 35 months & Pregant Women
2019-2020 YMCA Early Learning Academies
2019-2020 Head Start
No Cost Preschool, Pre-K, AM/PM Care for Children 3 - 5,
1st Location Preference
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2nd 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
Required information is missing, see above.