KTDC Free Programs Registration

Free Childcare Programs Application

Please complete this application to apply for our Early Head Start/Head Start Program or Preschool for All/Prevention programs through Kids Tech Discovery Center. Applications will be reviewed within 2 business days. If you need to speak with a staff member sooner and/or have an urgent matter, please call us at 1.708.201.7300
Child's Information
Child's Name*

First NameLast Name
Birth Date

MonthDayYear
2nd Child's Name (if applicable)

First NameLast Name
2nd Child's Birth Date (if applicable)

MonthDayYear
How did you hear about our program?*

Social MediaInternet SearchA friend or relativeOther
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Primary Phone #*
E-mail*
example@example.com
City of residence*
Zip Code*
Household income*

$0 - $4,999$5,000 - $9,999$10,000 - $14,999$15,000 - $19,999$20,000+
Family size*
Are you currently employed?*

Yes (I am currently employed)No (I am not currently employed)
How soon are you interested in starting*

1 - 3 Days3 days - 2 Weeks3 Weeks+
Are you able to transport your child to a center?*

Yes (as long as it's not too far)Yes (I would be willing to for the right program)No (I need services right in my neighborhood)No (I need services to/from my home)
Have you been approved for a Child Care Subsidy?*

YesNoI don't know
Does your child have a chronic medical condition or health concern? (such as asthma, diabetes, food allergy/intolerance)

NoIf Yes, please explain below
Explain here:
Comments/Notes
Should be Empty:

Free Childcare Programs Application