SKCDC - Southern Kennebec Child Development Corporation

Head Start

Application Form for Expectant Families

Name of Applicant(s):

Family Status

Number of children residing in the home

What is your family's gross income?

Weekly			Monthly			or Yearly
How many people in your household are supported by this income?

One Person we may call to help reach you:

Name

Phone

Due Date for Newborn:

Specify your plans for work/school/training after your child is born:

Mother:
Father:

When do you expect child care will be needed?

Are you currently receiving services from:

KVCAP Healthy Families	TANF/ASPIRE	WIC
Parents as Teachers (PAT) Maine Parent Federation	Public Health Nursing	Child Care Options
Other:

Signature of applicant:

______________________________Date_______________

Upon completing the form, PRINT IT, SIGN IT, and DATE IT and send it to:

Southern Kennebec Child Development Corporation
99 Western Ave. Suite 6
Augusta, ME 04430

Early Head
Start

HomeStart

Child Care

Collaborations

Employment Opportunities

About SKCDC