Kids On The Move

1. Child's Name*
2. Child's Birth Date
3. Phone
4. Address
5. City*
6. Zip Code / Postal Code*
7. Your Name
8. Your Birthday
9. Email Address
10. Name of other parent
11. Marital Status
12. Single Married Separated Divorced Widow Co-habitating
13. What language(s) do you speak?
14. Are you a first time parent?
15. Yes No
16. Physicians Name
17. If expecting a baby, what is the due date?
18. How many children do you have and what are their ages?
19. Is your income at or below that listed for your family size?
20. Is this child a foster child?
21. Yes No
22. What is the highest level of education you have completed?
23. What is the highest level of education the other parent has completed?
24. Your current job status?
25. Full-time Part-time Unemployed In school
26. Other parent's current job status?
27. Full-time Part-time Unemployed In school
28. Is your child currently in child care?
29. Yes No
30. If yes, where?
31. Do you need child care?
32. Yes No
33. Has anyone in your family been diagnosed with a disability?
34. Yes No
35. If yes, who?
36. Child Mother Father Other
37. Do any of the following apply to you, the other parent, or your child?
38. Substance abuse Child abuse or neglect Domestic violence Serious family crisis
39. How did you hear about Early Head Start?*
40. Is there anything else you would like us to know about your family or child?

 

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Eligibility

• Child under 3 years old
• Family resides in Utah County
• Family is low income or the child has a disability

Waiting List

Early Head Start is funded to serve only 164 families at a time. When there is no space available, families are placed on a waiting list in order of application. Risk factors are weighted so that families with more need can move more quickly to the head of the line. We will call families on the wait list when there is an opening in the program (often within a few months).

What happens when you apply?

1. We will call you shortly after receiving your application.
2. We will set up an appointment to visit you at home to verify all information.
3. We will tell you if you will be on the waiting list, or if there is room now.
4. If there is room, we will complete all paperwork to enroll you in the program and start services.

To submit the application:

Click the “submit” button to send your application on-line. You may also print and mail it to us at 475 West 260 North, Orem, 84057.