1. Complete each page. Please print.
2. Sign and date the enrollment form and contact sheet.
3. Return application with a copy of the following:
   •  Family Income (Ex. W2, 1040 Tax Form, TANF, Child Support, & SSI) 
   • Child’s Birth Certificate 
   • Parent/Legal Guardian’s State Identification (Ex. Drivers License)  
   • Child’s Medicaid/Insurance Card
4. An in-person interview must be conducted in order to complete the application process. The interview will be scheduled by the Family Service Associate.
5. Contact us immediately if there are any changes in your address or telephone number.
6. The following items will be required if accepted for enrollment (please be proactive in obtaining this paperwork):
   • Child’s Immunization Record (original blue card) 
   • Physical Examination/Assessment Form
   • Dental Examination/Treatment Form
   • IEP/IFSP (If Applicable) 

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