Center Based Child Application

Head Start is a federally funded program designed to help children from low-income families develop the skills they need for success in school and life.

Children from birth to age five are eligible for Head Start and Early Head Start if their family’s income is below federal poverty guidelines. Additionally, children and families in the following categories are also eligible:
- families experiencing homelessness
- families receiving public assistance like TANF, ATAP, SNAP, or SSI
- Foster children, regardless of the foster family’s income
After submitting an application, families will need to participate in an eligibility interview with our enrollment staff to determine what documents are required to verify eligibility.
How do you think your family qualifies for Head Start services?

Other

Center Based Child Application

Kids' Corps offers infant/toddler and preschool classes for children from 4 month to 5 years of age. There are several locations and program options available for families in the Anchorage area.
What age is the child you are applying for?
Due date:

MonthDayYear
Date
Early Head Start Program Options & Locations: Child Must be a minimum of 4 months old to be enrolled in Center Based.
Head Start Program Options & Locations
Do you have any concerns or comments you'd like us to know about regarding your unborn child?
Early Head Start Program Options & Locations:
Child' Full Name:

First NameLast Name
Child's Date of Birth:

MonthDayYear
Date
Child's Sex
Child's Primary Language:
Child's Secondary Language:
Does your child have any disability or special need? (either diagnosed or suspected)
If yes, please explain:
Do you have concerns about your child’s development?
If yes, please explain:
Does your child have an IEP or an IFSP?
If yes, please explain:
Does your child have a sibling enrolled in the program?
Sibling/s full name:
Do you have a 2nd child you want add to the application?
What age is the 2nd child you are applying for?
Due date of child #2:

MonthDayYear
Date
Child #2: Early Head Start Program Options & Locations: Child Must be a minimum of 4 months old to be enrolled in Center Based.
Child #2: Do you have any concerns or comments you'd like us to know about regarding your unborn child?
Child #2: Head Start Program Options & Locations
Child #2: Early Head Start Program Options & Locations:
Child #2 Full Name:

First NameLast Name
Child #2 Date of Birth:

MonthDayYear
Date
Child #2 Sex:
Child #2 Primary Language:
Child #2 Secondary Language:
Child #2: Does your child have any disability or special need? (either diagnosed or suspected)
Child #2 If yes, please explain:
Child #2: Do you have concerns about your child’s development?
Child #2: If yes, please explain:
Child #2: Does your child have an IEP or an IFSP?
Child #2: If yes, please explain:
Do you have a 3rd child you want add to the application?
What age is the 3rd child you are applying for?
Due date of child #3:

MonthDayYear
Date
Child #3: Early Head Start Program Options & Locations: Child Must be a minimum of 4 months old to be enrolled in Center Based.
Child #3: Do you have any concerns or comments you'd like us to know about regarding your unborn child?
Child #3: Head Start Program Options & Locations
Child #3: Early Head Start Program Options & Locations:
Child #3 Full Name:

First NameLast Name
Child #3 Date of Birth:

MonthDayYear
Date
Child #3 Sex:
Child #3 Primary Language:
Child #3 Secondary Language:
Child #3: Does your child have any disability or special need? (either diagnosed or suspected)
Child #3 If yes, please explain:
Child #3: Do you have concerns about your child’s development?
Child #3: If yes, please explain:
Child #3: Does your child have an IEP or an IFSP?
Child #3: If yes, please explain:
Primary Parent/Guardian Full Name:

First NameLast Name
Primary Parent/Guardian Date of Birth:

MonthDayYear
Date
Relationship to child/children:
Primary Parent/Gurdian Sex:
Primary Parent/Gurdian's Primary Language:
Primary Parent/Gurdian's Secondary Language:
Employment Status:
Primary Parent/Guardian Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:
May we contact you by text message?
Alternate Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type:
Primary Parent/Gurdian Email:
example@example.com
Physical Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is mailing address the same as physical?
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there a Secondary Parent/Guardian?
Household Parental Status
Secondary Parent/Guardian Full Name:

First NameLast Name
Secondary Parent/Guardian Date of Birth:

MonthDayYear
Date
Relationship to child/children:
Secondary Parent/Gurdian Sex:
Secondary Parent/Gurdian's primary language:
Secondary Parent/Gurdian's Employment Status:
Secondary Parent/Guardian phone number
Please enter a valid phone number.Format: (000) 000-0000.
Phone type:
May we contact you by text message?
Alternate Secondary Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone type:
Does Secondary Parent/Guardian share physical address with primary?
Secondary Parent/Guardian's physical address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Secondary Parent/Guardian's mailing address the same as physical?
Secondary Parent/Guardian's mailing address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Type

Other
Number in Family:
Number of Children Ages 0 - 35 Months:
Number of Children Ages 3 - 5 Years:
Total Number of Persons in the Home:
Are you currently a teen parent?
Has your child previously been enrolled in any Kids' Corps program?
Did Primary Parent/Guardian receive the most recent Alaska PFD?
Did Secondary Parent/Guardian receive the most recent Alaska PFD?
Estimated Annual Household Income:
Do you need care for your child/ren while you are at work or school?
If yes, who currently provides care?
Has your child/ren previously been enrolled in another Early Head Start or Head Start program?
Please explain:
Family Housing Status:

Other
Has your family experienced homelessness in the past 6 months?
Please explain:
Are you currently receiving ATAP and/or SNAP?
Case number:
Is your family experiencing a special hardship or crisis?
If yes, explain:
Were you referred by another agency or provider?
If yes, who?
If a Head Start bus is not available, can you provide transportation for your child?
Please tell us about your transportation difficulties:
How did you hear about KCI?

Other
What is the best way to contact you to follow up on your child's application?
Would you like to complete the eligibility interview in-person or over the phone?
Required Documents

For Kids’ Corps staff to verify your child’s Head Start eligibility, you will need to submit the following documents:
- Proof of current ATAP or SNAP benefits or
- Income information for all income sources for a full 12 months (W-2, 1040 tax form, child support, unemployment benefits, ATAP printout, LES, pay stubs, etc.) or
- documentation that the child is in foster care or the family is currently homeless and
- A copy of your child’s birth certificate (if available)
If you have these documents available you can upload them now or scan them to our Enrollment Specialist at miriam@kcialaska.org or drop them at our East Center (3710 E. 20th Avenue).

Documents can be submitted before, during or after your eligibility interview.

If there are barriers to getting the required documents, please let us know and we can assist you.
Documents Upload:

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