Please complete the brief information needed below. Once completed, a staff member will contact you to finalize the application.
Applicant Child's Last Name (as it appears on the birth certificate)
Applicant Child's First Name
Applicant Child's Date of Birth
Primary Guardian Last Name
Primary Guardian First Name
Primary Guardian Email Address
Primary Guardian Phone Number
Does the applicant have an Individualized Family Service Plan (IFSP)?
Does the applicant have Individualized Education Plan (IEP)?
Does anyone in your family receive Supplemental Security Income (SSI)?
Does your family receive Temporary Assistance for needy families (TANF)?
Does your family receive food stamp benefits?
Primary Address
Mailing Address (if different)
Address Line 1:
Address Line 2:
City:
State:
Zip: