HS/EHS Application

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

Is English your first language?(Required)
Program Option Applying for:(Required)
Professionally diagnosed disability, special health/ dietary concern, or food allergy?(Required)

Mother / Guardian Information

Mother / Guardian Name(Required)
Date of Birth(Required)
Are you the natural parent of the child?(Required)

Father / Guardian Information

Father / Guardian Name
Address if different from above:
Date of Birth
Are you the natural parent of the child?
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.
This field is for validation purposes and should be left unchanged.