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 Name Last Name
Birth Date

Month Day Year
2nd Child's Name (if applicable)

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

Month Day Year
How did you hear about our program? *

Social Media Internet Search A friend or relative Other
Parent/Guardian Information
Parent/Guardian Name *

First Name Last 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 Days 3 days - 2 Weeks 3 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? *

Yes No I don't know
Does your child have a chronic medical condition or health concern? (such as asthma, diabetes, food allergy/intolerance)

No If Yes, please explain below
Explain here:
Comments/Notes
Should be Empty:

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Free Childcare Programs Application