- Complete each page. Please print.
- Sign and date the enrollment form and contact sheet.
- 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
- An in-person interview must be conducted in order to complete the application process. The interview will be scheduled by the Family Service Associate.
- Contact us immediately if there are any changes in your address or telephone number.
- 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)