Interested in applying for Pathways for Children's education programs? You're in the right spot! Fill out the application below.
Application date
-
Month
-
Day
Year
Date
Primary Parent/Guardian
Name
*
First Name
Middle Name
Last Name
Email
*
example@example.com
Birthday
*
-
Month
-
Day
Year
Date
Gender
*
Race
*
American Indian/Alaska Native
Asian
Black
Hawaiian/Pacific Islander
Multi-Racial
White
Hispanic
*
Please Select
Yes
No
English Proficiency
*
None
Little
Moderate
Proficient
Other Language
Other Language Proficiency
None
Little
Moderate
Proficient
Highest Grade Completed
*
Less than Grade 9
Grade 10
Grade 11
Grade 12
GED
High School Graduate
College or Advanced Training
Associate's Degree
Bachelor's Degree
Master's Degree
Employment Status
*
Please Select
Full Time
Full Time & Training
Part Time
Part Time & Training
Seasonal
Training or School
Unemployed
Retired or Disabled
Child's Relationship to Applicant
*
Biological, Adopted, or Step Child
Grandchild
Other Relative
Foster
Other
Do you have custody of the child?
*
Please Select
Yes
No
Check all that apply
*
I live with the family
I provide financial support
Contact Information
Email
*
example@example.com
Family Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number 1
*
Please enter a valid phone number.
Phone Type
*
Please Select
Mobile Phone
Home Phone
Work Phone
Other
Opt in for Text Messages?
*
Please Select
Yes
No
Is there another phone number you'd like to add?
*
Please Select
Yes
No
Phone Number 2
*
Please enter a valid phone number.
Phone Type
Please Select
Mobile Phone
Home Phone
Work Phone
Other
Opt in for Text Messages?
Please Select
Yes
No
Is there another phone number you'd like to add?
*
Please Select
Yes
No
Phone Number 3
*
Please enter a valid phone number.
Opt in for Text Messages?
Please Select
Yes
No
Phone Type
Please Select
Mobile Phone
Home Phone
Work Phone
Other
Back
Next
Family History
How many parents live in the home?
*
Please Select
One
Two
What is the primary language spoken at home?
*
Please choose all that apply
*
Homeless family
Active duty military
Military veteran
Receiving SNAP
Receiving WIC
Not applicable
Is there a secondary guardian/parent living at the same address as the family?
Please Select
Yes
No
Back
Next
Secondary Guardian/Parent Information
Name
*
First Name
Middle Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Gender
*
Race
*
American Indian/Alaska Native
Asian
Black
Hawaiian/Pacific Islander
Multi-Racial
White
Hispanic
*
Please Select
Yes
No
English Proficiency
*
None
Little
Moderate
Proficient
Other Language
Other Language Proficiency
None
Little
Moderate
Proficient
Highest Grade Completed
*
Less than Grade 9
Grade 10
Grade 11
GED
High School Graduate
College Degree/Training
College or Advanced Training
Associate's Degree
Bachelor's Degree
Master's Degree
Other
Employment Status
*
Please Select
Full Time
Full Time & Training
Part Time
Part Time & Training
Seasonal
Training or School
Unemployed
Retired or Disabled
Child's Relationship to Secondary Guardian/Parent
*
Biological, Adopted, or Step Child
Grandchild
Other Relative
Foster
Other
Does this secondary guardian/parent have custody of the child?
*
Please Select
Yes
No
Check all that apply
*
Lives with the family
Provides financial support
Please choose all that apply
*
Homeless family
Active duty military
Military veteran
Receiving SNAP
Receiving WIC
Not Applicable
Secondary Guardian/Parent Contact Information
Email
*
example@example.com
Phone Number 1
*
Please enter a valid phone number.
Phone Type
*
Please Select
Mobile Phone
Home Phone
Work Phone
Other
Opt in for Text Messages?
*
Please Select
Yes
No
Is there another phone number you'd like to add?
*
Please Select
Yes
No
Phone Number 2
Please enter a valid phone number.
Phone Type
Please Select
Mobile Phone
Home Phone
Work Phone
Other
Opt in for Text Messages?
Please Select
Yes
No
Is there another phone number you'd like to add?
*
Please Select
Yes
No
Phone Number 3
Please enter a valid phone number.
Opt in for Text Messages?
Please Select
Yes
No
Phone Type
Please Select
Mobile Phone
Home Phone
Work Phone
Other
Back
Next
Enrolling Child
Name
*
First Name
Middle Name
Last Name
Select the program you are applying to:
*
Head Start - for children ages 2 years, 9 months to 5 years old
Early Head Start - for 15 months to age 2 years, 9 months
School Aged Care - for children from kindergarten -12 years old
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's Gender
*
Child's Allergies or Health Conditions
*
Child's Race
*
American Indian/Alaska Native
Asian
Black
Hawaiian/Pacific Islander
Multi-Racial
White
Hispanic
*
Please Select
Yes
No
Child's English Proficiency
*
None
Little
Moderate
Proficient
Other Language
Other Language Proficiency
None
Little
Moderate
Proficient
Name of Primary Health Insurance
*
Other Coverage
Insurance Number
*
Child's Pediatrician
*
Pediatrician's Phone Number
*
Please enter a valid phone number.
Child's Dentist
*
Dentist's Phone Number
*
Please enter a valid phone number.
Are there additional siblings in the household?
*
Please Select
Yes
No
Back
Next
Sibling 1 Information
Name
*
First Name
Middle Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's Gender
*
Child's Race
*
American Indian/Alaska Native
Asian
Black
Hawaiian/Pacific Islander
Multi-Racial
White
Hispanic
*
Please Select
Yes
No
Child's English Proficiency
*
None
Little
Moderate
Proficient
Other Language
Other Language Proficiency
None
Little
Moderate
Proficient
Are there additional siblings in the household?
*
Please Select
Yes
No
Back
Next
Sibling 2 Information
Name
*
First Name
Middle Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's Gender
*
Child's Race
*
American Indian/Alaska Native
Asian
Black
Hawaiian/Pacific Islander
Multi-Racial
White
Hispanic
*
Please Select
Yes
No
Child's English Proficiency
*
None
Little
Moderate
Proficient
Other Language
Other Language Proficiency
None
Little
Moderate
Proficient
Are there additional siblings in the household?
*
Please Select
Yes
No
Back
Next
Sibling 3 Information
Name
*
First Name
Middle Name
Last Name
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's Gender
*
Child's Race
*
American Indian/Alaska Native
Asian
Black
Hawaiian/Pacific Islander
Multi-Racial
White
Hispanic
*
Please Select
Yes
No
Child's English Proficiency
*
None
Little
Moderate
Proficient
Other Language
Other Language Proficiency
None
Little
Moderate
Proficient
Back
Next
Emergency Contact Information
Name
*
First Name
Last Name
Relationship to Child
*
Emergency Contact
*
Please Select
Yes
No
Can this emergency contact pick your child up from our program?
*
Please Select
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number 1
*
Please enter a valid phone number.
Phone 1 Type
*
Please Select
Mobile/Cell
Work
Home
Phone Number 2
*
Please enter a valid phone number.
Phone 2 Type
*
Please Select
Mobile/Cell
Work
Home
Phone Number 3
Please enter a valid phone number.
Phone 3 Type
Please Select
Mobile/Cell
Work
Home
Do you have an additional emergency contact?
Please Select
Yes
No
Back
Next
Additional Emergency Contact
Name
*
First Name
Last Name
Relationship to Child
*
Emergency Contact
*
Please Select
Yes
No
Can this emergency contact pick your child up from our program?
*
Please Select
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number 1
*
Please enter a valid phone number.
Phone 1 Type
*
Please Select
Mobile/Cell
Work
Home
Phone Number 2
*
Please enter a valid phone number.
Phone 2 Type
*
Please Select
Mobile/Cell
Work
Home
Phone Number 3
Please enter a valid phone number.
Phone 3 Type
Please Select
Mobile/Cell
Work
Home
Do you have an additional emergency contact?
Please Select
Yes
No
Back
Next
Additional Emergency Contact
Name
*
First Name
Last Name
Relationship to Child
*
Emergency Contact
*
Please Select
Yes
No
Can this emergency contact pick your child up from our program?
*
Please Select
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number 1
*
Please enter a valid phone number.
Phone 1 Type
*
Please Select
Mobile/Cell
Work
Home
Phone Number 2
*
Please enter a valid phone number.
Phone 2 Type
*
Please Select
Mobile/Cell
Work
Home
Phone Number 3
Please enter a valid phone number.
Phone 3 Type
Please Select
Mobile/Cell
Work
Home
Back
Next
How did you hear about our program?
*
Outside Agency
Social Media
Word of Mouth/ Referral
Postcard/flyer
Community Event
Pathways' Staff*
Friend*
Other
If you chose "Pathways' Staff" or "Friend" above, please state their name:
blanks
*
If you chose "Community Event" or "Other" above, please list which community event you attended or how you heard about our program?
Submit
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