HS/EHS Application

Please fill out all fields to submit a pre-application. After you have submitted your information, a Family Services Worker will contact you to schedule an appointment to complete the application process.

Eligible Children Information

Child's Name(Required)

First Middle Last

Birthday(Required)

Gender

Is English your first language?(Required)

Yes

If no, what is your first language?(Required)

Professionally diagnosed disability, special health/ dietary concern, or food allergy?(Required)

Yes

If yes, please explain:

Parents / Guardian Information

Mother / Guardian Name(Required)

First Middle Last

Date of Birth(Required)

Gender

Are you pregnant?(Required)

Yes

Estimated due date:(Required)

Cell Phone

Mobil

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

Father / Guardian Information

Name

First Middle Last

Date of Birth

Gender

Phone

Address is the same as above

Yes

Address if different from above:(Required)

Street Address Address Line 2 City State ZIP Code

The information requested is needed to help us establish your family's eligibility for the program. Please be advised this application is strictly confidential and voluntary. Any information regarding sex, education, or disability is gathered for statistical purposes only. This agency does not discriminate in any way in provision of services.

Phone

This field is for validation purposes and should be left unchanged.

Eligible Children Information

Parents / Guardian Information

Father / Guardian Information

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