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Mid Michigan Community Action Agency Early Childhood Services On-line Interest Form for Early Head Start. Please remember that this is not an application - it is our way for you to share with us your interest in our program. If you have previously been enrolled, you will need to call to complete the next step in the process. 1-877-386-4406

Parent/Legal Guardian 1 If you answered Yes to Custody Arrangement, please include, other custodial parents name, DOB, email address and phone number in the Custody Arrangement Notes section

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (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

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

Hispanic

Lives with Family

English Proficiency

Other Language

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Custody Arrangement

Alias/Other Names

Address

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

Parent/Legal Guardian 2

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

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

Hispanic

Lives with Family

English Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Alias/Other Names

Are there other adults in the household?

Add Another Adult

Additional Family Information

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? (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

Child/PW (applicant)

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

Race

Hispanic

Lives with Family

English Proficiency

Primary Health Coverage

PW Expected Due Date

How did you hear about us

If, Other indicate

Alias/Other Names

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 your interest in Early Head Start. Please click submit if you have answered all questions to the fullest and best you can. Someone from our office will be contacting you soon.

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