Enrollment

Vital Connections of the Midlands Early Head Start Enrollment Application

Complete and submit form below, or download printable pdf here.

Parent Sign-Up Form

Enrollment Application

Name(Required)

Childs Name(Required)

Nickname (if your child has one)

Phone Number for the Primary Parent(Required)

Phone Number for the Secondary Parent

Birthday(Required)

Gender(Required)

Male

Female

Race(Required)

Black

White

Asian

American Indian / Alaska Native

Hawaiian / Pacific Island

Multi-Racial

Other

Hispanic

Yes

No

English Proficiency

Little

Moderate

Proficient

None

Does Your Child Speak Another Language?

Yes

No

Insurance

Perferred Center Location

Tender Years (Hopkins)

Arthurtown (Riley St.)

Childrens Garden (Blue Ridge Terrace)

Primary Health Coverage

Medicaid

No Insurance

Other

Medicaid #

Doctor / Medical Home

Dental Coverage

Medicaid

No Insurance

Other

Dental Coverage #

Dentist / Dental Home

Does Your Child Have a Current IEP or IFSP?

Yes

No

Does Your Child Have a Disability?

Yes

No

Primary Adult Name

Email Address

Employment Status

Unemployed

Part Time

Full Time

Full Time & Training

Looking for Employment

Retired or Disabled

Training & School

Part Time & Training

Marital Status

Single

Divorced

Married

Widowed

Highest Level Of Education

High School Diploma / GED

Non Diploma

College / Training

Associates

Bachelors

Other

Relationship With Child

Secondary Adult

Email Address

Marital Status

Single

Divorced

Married

Widowed

Relationship With Child

Highest Level Of Education

High School Diploma / GED

Non Diploma

College / Training

Associates

Bachelors

Other

Employment Status

Unemployed

Part Time

Full Time

Full Time & Training

Looking for Employment

Retired or Disabled

Training & School

Part Time & Training

Other Children

Yes

No

Name

How Long Have You Lived At Current Address?

Current Address

Living Address 2

City

State

Zip Code

Parental Status

1

2

Primary Language At Home?

Active Military Duty?

Yes

No

Acquired or Learning A Language Other Than English?

Yes

No

Referred By Child Welfare?

Yes

No

Receiving SNAP?

Yes

No

Receiving WIC?

Yes

No

Homeless Family?

Yes

No

Receiving SSI?

Yes

No

TANF Status?

Yes

No

Is Child Living With Relatives Due To Abandonment?

Yes

No

Is Child Living With Relatives Due To Incarceration?

Yes

No

Is There Any Specific Family Need or Crisis?

Yes

No

Emergency Contact Name

Emergency Contact?

Yes

No

Release To

Yes

No

Address

City

State

Zip Code

Phone Number

Type of Phone

Cell

Home

Work