Welcome!

Preschool Picture

Are you pregnant or have a young child under the age of 3? We have just the program for you! Fill out our Early Head Start interest form below or call our toll free number 1-877-386-4406 to get more information on our high quality program for pregnant women and children from birth through 3 years of age. Click on the About Us link on the left hand side of the screen. Any family wishing to apply in Clare, Gladwin, Midland, Mecosta or Osceola counties, must complete the interest form.

Mid Michigan Community Action Agency Logo


Interest Form

I am completing this Interest Form for:
A child
Myself, I am pregnant
Child's Name:

Date of Birth:
Gender: Male
Female
Ethnicity:
(check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic of any race
Unknown
County:
Address:

Parent/Guardian Information
Parent/Guardian 1:

Parent/Guardian 2:

Providing your email address will ensure regular communication about Early Head Start.
Phone Number:

() -

Alternate Number:

() -

How would you prefer to be contacted?
 Phone
 Email
Marital Status:
Single
Married
Divorced
Widow
Separated
Partner
Child Lives With:
(check all that apply)
Mother
Father
Both Parents
Joint Custody-Physical
Joint Custody Legal
Foster Care
Legal Guardian
Grandparent
Other:
Number of people living in the household:

Parent/Guardian 1 Income Information
Parent/Guardian 1 Gross Income:
Income before taxes or other deductions. Verification of income will be required.

Choose the period the above wage represents:

Parent/Guardian 1 Income Source:
(check all that apply)
Working
Child Support
Supplemental Security Income (SSI)
Other:
Is this more than stated on Parent/Guardian 1's 2019 income tax return?

Yes   No

Have there been any income changes for either Parent/Guardian in the last 6-12 months?
(i.e., unemployment, wage increase/decrease, etc.)

Yes   No

Additional Information
Is there additional information that you can share about your child/family?
Rollover highlighted text for definitions.
Explain any concerns checked:
(i.e., evaluations, specialist, parent concern, lead count, primary language)

Is there a court order related to custody and/or visitation?:

Yes   No

Is your current address a temporary living arrangement?

Yes   No

Do you have reliable transportation?:
(for planning purposes only)

Yes   No

Has your child been referred/involved in:
(check all that apply)
Early Childhood Special Education
Early On
Current services received by family:
(check all that apply)
DHHS Child Care Assistance
DHHS Financial
DHHS Food Assistance
Medicaid
How did you learn about us?:
 Community Event
 Community Organization
 Currently Enrolled Family
 Facebook Page
 Flyer
 Friend/Family Member
 Letter in the Mail
 Newspaper/Ads
 Restaurant Placemat
 TV/Radio
 Teacher/Education Professional
 Website
 Other: