* - Required Field
    What type of program are you interested in applying for this child?
    Please specify
    Child Information
    First Name *
    Enter the child's legal first name as it appears on the birth certificate.
    Middle Name
    Last Name *
    Enter the child's legal last name as it appears on the birth certificate.
    Suffix
    Date of Birth *
    Gender *
    Address *
    Apartment/Unit Number
    City *
    State *
    ZIP Code *
    Resident District
    Has an Individualized Education Plan (IEP)
    Foster Child
    Is Child Homeless Info
    Primary home language other than English
    Language spoken In the home
    Are parents able to speak English?
    # of Household members
    including the child above
    Family member is any individual living in the house that is related to the child's parent/guardian by blood, marriage, or adoption who are financially supported by the income of the parent or guardian of the child enrolling or participating in the program.
    I choose not to enter my income
    If you do not enter your household income, you will not be considered for preschool tuition assistance.
    Annual Income
    Income means total cash receipts before taxes from all sources, with the exception of student loans for tuition and books.
    If a parent is an active member of the U.S. Armed Forces allowances for living, moving, family, death, and in-kind benefits are exempt. Disability, group-term life insurances, uniform allowances, and survivor and retirement protection plan premiums are also exempt.
    Income Documentation
    		The best documentation of income is a copy of the most recent tax return. If this is not available, 4 weeks of pay stubs, or W-2 form may be used until tax return is received. If you do not include documents you will be sent an email where you can upload them later, if you enter your email address. This is limited to 15MB.
    WARNING: Please black out social security numbers before uploading documents.
    Primary Contact - parent or legal guardian
    First Name *
    Last Name *
    Gender
    Relationship
    Primary/Home Phone *
    Secondary Phone
    Education Level
    Email Address
    Currently Working
    Other Parents/Guardians
    Add
    Last Name First Name Relationship Gender Education Level Cell Phone Email
    Head Start/Great Start Readiness Program questions
    Are you currently or were previously a teen parent
    Parent's Date of Birth
    Is either parent employed
    Times the child moved in the last year
    Severe or challenging behavior Info
    Diagnosed disability or identified developmental delay Info
    Child is an Immigrant or Refugee
    Child affected by loss of a parent/sibling Info
    Divorce
    Absence
    Military Service
    Death
    Incarceration
    Exposure to Domestic Violence or Substance Abuse
    Involvement with Child Protective Services, past or present
    Program Options
    Agency Preference Tuition Free Agency Map Agency Info
    For which year are you hoping to have your child enrolled or be considered for services?
    Desired Program Schedule
    Do you need transportation
    Is pick up/drop off different from home address
    Pick up address
    Drop off address
    Siblings - if you want to enroll additional children, use the Add Another Child button below.  Enter other siblings here.
    Add
    Last Name First Name Date Of Birth Gender
    Alternate Contact
    First Name
    Last Name
    Phone Number
    Authorization
    By submitting this application you acknowledge that the information given within will be shared with Help Me Grow-Ottawa.