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Welcome!

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.

Interest Form

I am completing this Interest Form for:

A child
Myself, I am pregnant

Child's Name:

First Name:

Middle Name:

Last Name:

Date of Birth:

Gender: Male
Female

Ethnicity:

(check all that apply)

County:

Address:

Street Address:

Street Address 2:

City:

Zip Code:

Parent/Guardian Information

Parent/Guardian 1:

First Name:

Last Name:

Parent/Guardian 2:

First Name:

Last Name:

Email Address:

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:

Number of people living in the household:

Number of Adults:

Number of Children:

Parent/Guardian 1 Income Information

Parent/Guardian 1 Gross Income:

Income before taxes or other deductions. Verification of income will be required.

Wages: $

Choose the period the above wage represents: Weekly Bi-Weekly Monthly Annually

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 2023 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?:

Mid Michigan Community Action Agency provides equal membership/employment/service opportunities to all eligible persons without regard to race, religion, color, national origin, citizenship, age, sex, marital status, parental status, handicap, membership of any labor organization, political affiliation, and for employment only, height, weight and record of arrest without conviction.

This site was developed by Clinton County RESA Office of Innovative Projects with funds from a grant awarded by the Michigan Department of Education.