Form Test

Thank you for your interest in our program for young children. Please complete the following form to begin the application process.

Hidden
Recruitment Event
Field used to track if applicant reached site via a recruitment event
Initial Application
- All applications for enrollment in our program go through a detailed selection process that helps us to select children and families with the highest need of our services.
- This selection process will begin in early summer and continue until classes are full.
- Should your child not be selected, they will be placed on a waiting list. This will not guarantee you a slot this year, but it will leave the possibility open as vacancies occur.
Child's Legal Name*
First Middle Last
Date of Birth*
Parent/Guardian Name:*
First Middle Last
How did you hear about us?*
Name of person/organization who told you about our programs:
Are you currently receiving assistance through any Opportunity Council programs or departments?*
- Yes
- No
Please indicate which service:
Name of Case Manager

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About Your Family
Language(s) Spoken:*
Parents need interpreter?*
- Yes
- No
Number in Family*
Please enter a number greater than or equal to 1.
Household Type*
- One-Parent Household
- Two-Parent Household
Number of children 0-3 years old:*
Please enter a number greater than or equal to 0.
Number of children 4 or 5 years old:*
Please enter a number greater than or equal to 0.
Is anyone is your family pregnant?*
- Yes
- No
If yes, what is the due date?
Is your family currently receiving service through TANF, or have you in the past year?*
- Yes
- No

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Please list everyone living in the household who may be counted in family size:

Name	Relationship	Date of Birth

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Concerns and Challenges
Please share your concerns and challenges
Select all that apply to you or your family.
Premature birth, if yes, how early:
Homeless is defined as sharing the housing of other persons due to loss of housing or economic hardship; are living in motels, hotels, trailer parks, or camping grounds due to lack of alternative adequate accommodations; are living living in emergency or transitional shelters (McKinney-Vento Homeless Assistance Act)
Circumstances that you would like to share:
This may qualify you for additional program supports.

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Certification
I certify that the information provided in the Early Learning and Family Services Head Start/ECEAP/Early Head Start Intake Application is accurate and truthful to the best of my knowledge. I authorize and consent to exchanging my household information within the departments in the Opportunity Council agency.*
Type name to certify
Email*
Optional - Verification of Age and Income File Upload
If scanned copies are unavailable, Verification of Age and Income can be mailed or submitted in person. Your application will not be complete until all items have been received.
Upload Verification of Income
Either the last 12 months or the last calendar year.
Max. file size: 25 MB.
Upload Verification of Child’s Age
Birth Certificate or Hospital Certificate
Max. file size: 25 MB.
Email
This field is for validation purposes and should be left unchanged.

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Initial Application