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?

We are a low-income familyWe receive public assistance (ATAP, TANF, SSI, or SNAP)We are experiencing homelessnessI am a foster parent applying for a foster childI'm not sure (that's okay! apply and we'll discuss it more)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?*

Not born yet0-35 months old3-5 years old
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.*

EHS East Center 7:30am-5:30pm (child care assistance contract required, co-pay fees may apply)EHS East Center 8:15 am-3:00 pm (no fees or child care assistance contract required)EHS Mt. View Center 8:15 am-3:00 pm (no fees or child care assistance contract required)EHS Mt. View Center 7:30am-5:30pm (child care assistance contract required, co-pay fees may apply)
Head Start Program Options & Locations*

East Center Full-Day 7:30am-5:30pm (child care assistance required, co-pay fees may apply) (year round)East Center Part-Day 8:30am-1:30pm (late August-May)Boniface Center 9:00 am-2:00pm (late August-May)Muldoon Center 9am-2pm (late August-July)-limited transportation availableRidgeline Center 8:30am-3:00pm (late August-May)
Do you have any concerns or comments you'd like us to know about regarding your unborn child? *
Early Head Start Program Options & Locations:*

EHS East Center 7:30am-5:30pm (child care assistance contract required, co-pay fees may apply)EHS Mt. View Center 8:15 am-3:00 pm (no fees)EHS Mt. View Center 7:30am-5:30pm (child care assistance contract required, co-pay fees may apply)
Child' Full Name:*

First NameLast Name
Child's Date of Birth:*

MonthDayYear
Date
Child's Sex*

MaleFemale
Child's Primary Language:*
Child's Secondary Language:
Does your child have any disability or special need? (either diagnosed or suspected)*

YesNo
If yes, please explain: *
Do you have concerns about your child’s development?*

YesNo
If yes, please explain: *
Does your child have an IEP or an IFSP?*

YesNo
If yes, please explain: *
Does your child have a sibling enrolled in the program?*

YesNo
Sibling/s full name: *
Do you have a 2nd child you want add to the application?*

YesNo
What age is the 2nd child you are applying for?*

Not born yet0-35 months old3-5 years old
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.*

EHS East Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)EHS Mt. View Center (9am-3pm, no fees or child care assistance contract required)EHS Mt. View Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)
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*

East Center Full-Day 7:30am-5:30pm (child care assistance required, co-pay fees may apply) (year round)East Center Part-Day 8:30am-1:30pm (late August-May)Muldoon Center 9am-2pm (late August-July)-limited transportation availableRidgeline Center 8:30am-3:00pm (late August-May)Baxter Elementary 8:30am-1:30pm (late August-May)Tudor Elementary 8:30am-1:30pm (late August-May
Child #2: Early Head Start Program Options & Locations:*

EHS East Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)EHS Mt. View Center (8:30am-3pm, no fees)EHS Mt. View Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)
Child #2 Full Name:*

First NameLast Name
Child #2 Date of Birth:*

MonthDayYear
Date
Child #2 Sex:*

MaleFemale
Child #2 Primary Language:*
Child #2 Secondary Language:
Child #2: Does your child have any disability or special need? (either diagnosed or suspected)*

YesNo
Child #2 If yes, please explain: *
Child #2: Do you have concerns about your child’s development?*

YesNo
Child #2: If yes, please explain: *
Child #2: Does your child have an IEP or an IFSP?*

YesNo
Child #2: If yes, please explain: *
Do you have a 3rd child you want add to the application?*

YesNo
What age is the 3rd child you are applying for?*

Not born yet0-35 months old3-5 years old
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.*

EHS East Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)EHS Mt. View Center (9am-3pm, no fees or child care assistance contract required)EHS Mt. View Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)
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*

East Center Full-Day 7:30am-5:30pm (child care assistance required, co-pay fees may apply) (year round)East Center Part-Day 8:30am-1:30pm (late August-May)Muldoon Center 9am-2pm (late August-July)-limited transportation availableRidgeline Center 8:30am-3:00pm (late August-May)Baxter Elementary 8:30am-1:30pm (late August-May)Tudor Elementary 8:30am-1:30pm (late August-May
Child #3: Early Head Start Program Options & Locations:*

EHS East Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)EHS Mt. View Center (8:30am-3pm, no fees)EHS Mt. View Center (7:30am-5:30pm, child care assistance contract required, co-pay fees may apply)
Child #3 Full Name:*

First NameLast Name
Child #3 Date of Birth:*

MonthDayYear
Date
Child #3 Sex:*

MaleFemale
Child #3 Primary Language:*
Child #3 Secondary Language:
Child #3: Does your child have any disability or special need? (either diagnosed or suspected)*

YesNo
Child #3 If yes, please explain: *
Child #3: Do you have concerns about your child’s development?*

YesNo
Child #3: If yes, please explain: *
Child #3: Does your child have an IEP or an IFSP?*

YesNo
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:*

MaleFemale
Primary Parent/Gurdian's Primary Language:*
Primary Parent/Gurdian's Secondary Language:
Employment Status:*

Full-TimePart-TimeUnemployedIn School/Training
Primary Parent/Guardian Phone Number:*
Please enter a valid phone number.
Phone Type:*

CellHomeWork
May we contact you by text message?*

YesNo
Alternate Phone Number:
Please enter a valid phone number.
Phone Type:

CellHomeWork
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?*

YesNo
Mailing Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there a Secondary Parent/Guardian?*

YesNo
Household Parental Status*

SingleTwo
Secondary Parent/Guardian Full Name:*

First NameLast Name
Secondary Parent/Guardian Date of Birth: *

MonthDayYear
Date
Relationship to child/children:*
Secondary Parent/Gurdian Sex:*

MaleFemale
Secondary Parent/Gurdian's primary language:*
Secondary Parent/Gurdian's Employment Status:*

Full-TimePart-TimeUnemployedIn School/Training
Secondary Parent/Guardian phone number*
Please enter a valid phone number.
Phone type:*

CellHomeWork
May we contact you by text message?*

YesNo
Alternate Secondary Parent/Guardian Phone Number
Please enter a valid phone number.
Phone type:

CellHomeWork
Does Secondary Parent/Guardian share physical address with primary?*

YesNo
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?*

YesNo
Secondary Parent/Guardian's mailing address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Type*

ParentGrandparentFosterOther
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?*

YesNo
Has your child previously been enrolled in any Kids' Corps program?*

YesNo
Did Primary Parent/Guardian receive the most recent Alaska PFD?*

YesNo
Did Secondary Parent/Guardian receive the most recent Alaska PFD?*

YesNo
Estimated Annual Household Income:*

Less than $25,000$25,000-$50,000$50,000-$75,000$75,000-$100,000$100,000+
Do you need care for your child/ren while you are at work or school?*

YesNo
If yes, who currently provides care? *
Has your child/ren previously been enrolled in another Early Head Start or Head Start program?*

YesNo
Please explain: *
Family Housing Status:*

RentOwnHomelessOther
Has your family experienced homelessness in the past 6 months?*

YesNo
Please explain:*
Are you currently receiving ATAP and/or SNAP?*

YesNo
Case number:
Is your family experiencing a special hardship or crisis?*

YesNo
If yes, explain:*
Were you referred by another agency or provider?*

YesNo
If yes, who?*
If a Head Start bus is not available, can you provide transportation for your child?*

YesNo
Please tell us about your transportation difficulties: *
How did you hear about KCI?*

Family, friend or neighborHead Start busKCI brochure/flier/rack cardRadioDoor HangerSocial MediaCommunity eventAgency referralWeb searchOther
What is the best way to contact you to follow up on your child's application?*

EmailPhone callText message
Would you like to complete the eligibility interview in-person or over the phone?*

In-person at 3710 E. 20th Avenue suite 2 (KCI East Center)Over the phone, please call me to schedule the interview
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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