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Child's Name *

First/Last

Does Your Child have Insurance *

If yes, Insurance Provider:

Date of Birth *

Select One *

Male
Female

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Parent/Guardian Name or Prenatal *

First/Last

Phone *

Date of Birth *

Select One *

Male
Female
Non-Binary/Non-Conforming
Prefer Not to Say

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Parent/Guardian Name *

First/Last

Phone *

Date of Birth *

Select One *

Male
Female
Non-Binary/Non-Conforming
Prefer Not to Say

Address *

Address Line 1

City

State

Zip Code

Mailing Address – if different than above:

Address Line 1

City

State

Zip Code

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Alternate Phone:

(other/work)

Language Spoken at Home *

Email *

Please list a relative/friend that does not live with you and can be contacted in case of emergency.

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Name *

Phone *

Relationship *

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Are you the biological/adopted/step parent of the child you are enrolling? *

Caseworker's Name *

First/Last

Are you a foster parent/legal guardian for the child you are enrolling? *

Caseworker's Phone *

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How many people are in the household? *

How many children are under age 5? *

How many children are in your family? *

Ages 0-18

Does your family: *

Rent
Own
Other

If other, please explain: *

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Does your child have a diagnosed disability? *

Please describe: *

Does your child have IFSP/IEP? *

Do you have any special concerns about your child?

(health, development, behavior, premature birth, etc.)

Please check income and benefits your family receives:

Income (select all that apply): *

TANF
SSI (Parent/Child)
Child Support/Alimony
Unemployment
Workers Comp
Active Military/Veteran
Foster/Adoption Subsidy
Grants/Scholarships
Other Cash Assistance
None

Benefits (select all that apply): *

WIC
SNAP
Financial Aid
HMK/CHIP
Energy Assistance
Housing Assistance
HMK+/Medicaid
Tribal
Best Beginnings
None

Employment Information

Please include employment information for all adults that financially contribute to the household.

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Are you employed? *

Full time/Part Time? *

Approx. how many hours per week?

Employer Information: *

Place Employed, Name of Supervisor, Work Phone Number

Is there another adult in the household that financially contributes?

Are you in school or training program? *

School/Training Program Information: *

What are you studying/training for? Approx. how many hours a week do you attend school/training?

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Are you employed? *

Full time/Part Time? *

Approx. how many hours per week?

Employer Information: *

Place Employed, Name of Supervisor, Work Phone Number

Are you in school or training program? *

School/Training Program Information: *

What are you studying/training for? Approx. how many hours a week do you attend school/training?

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Prenatal *

Due Date *

Is/Was your pregnancy considered "high risk?" *

Was your child born premature? *

If so, how early was your child born? *

Are you a teen parent? *

Are you a first time parent? *

By signing I certify the information provided is true and accurately reflects our current family situation.

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Signature *

Date *

Enrollment is based on priority points and number of slots available. Being eligible doesn't guarantee enrollment.

To enroll as a prenatal and/or your child, you will need this application plus:

Your child’s birth certificate and/or immunization record.
Your proof of income:
- 1040, W2, or paystubs (for past 12 months or calendar year)
  - OR proof of:
- SNAP, Current TANF, SSI, Foster Status, Child Residency Affidavit, or Zero Income

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Non-Discriminatory Clause:

U.S. federal law prohibits Anaconda-Deer Lodge County Head Start/Early Head Start from discriminating on the basis of race, sex, age, color, national origin, or disabilities in provision of services and employment.

Anaconda Head Start

Eligibility & Enrollment

Eligibility Requirements

Head Start Eligibility

Eligibility Documentation

Families must provide one form of documentation, listed above, to determine eligibility.

Please check income and benefits your family receives:

Employment Information

By signing I certify the information provided is true and accurately reflects our current family situation.

Enrollment is based on priority points and number of slots available. Being eligible doesn't guarantee enrollment.

To enroll as a prenatal and/or your child, you will need this application plus:

Your child’s birth certificate and/or immunization record.

Your proof of income:

1040, W2, or paystubs (for past 12 months or calendar year)

OR proof of:

SNAP, Current TANF, SSI, Foster Status, Child Residency Affidavit, or Zero Income

Non-Discriminatory Clause:

U.S. federal law prohibits Anaconda-Deer Lodge County Head Start/Early Head Start from discriminating on the basis of race, sex, age, color, national origin, or disabilities in provision of services and employment.