Home Visiting Program Child Application

Home Visiting Program Child Application

Kids' Corps, Inc. Home Visiting Program is for expecting families and families with children birth through five years of age. Participants in the program will receive two or four home visits each month with a trained Home Visitor or Parent Educator. Visits include information on development centered parenting (or fetal development and preparing for a new baby), a parent-child activity and resources to improve family well-being. Families are also invited to attend two group connection events each month.
What age is the child you are applying for?*

Not born yet0-35 months old3-5 years old
Due date: *

MonthDayYear
Date
Do you have any concerns or comments you'd like us to know about regarding your unborn child? *
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: Do you have any concerns or comments you'd like us to know about regarding your unborn child? *
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: Do you have any concerns or comments you'd like us to know about regarding your unborn child? *
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
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
Secondary Parent/Guardian Full Name:*

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

MonthDayYear
Date
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
Parental Status*

SingleTwo
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+
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?*
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
Our Home Based Program has a weekly or bi-weekly home visit schedule. Which is your preference?*

One visit per week (Early Head Start-income limits apply)Two visits per month (Parents as Teachers-no income limits)No preference
Eligibility interviews are required for Early Head start Services. Would you like to complete the eligibility interview in-person or over the phone?*

In-person at 101 Davis St.Over the phone, please call me to schedule the interviewI am only interested in Parents as Teachers (no interview required)
Required Documents

For Kids’ Corps staff to verify your child’s Early 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 miriamPAT@kcialaska.org or drop them at our home visiting office at 101 Davis St.

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:

Cancelof
Please verify that you are human*
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: