SHORE UP! Inc.
 
Thank you for your interest in applying for our Head Start or Early Head Start Programs. This application is the first step of the process. Your application is not complete until we: conduct a phone interview and verify income, residency and birth information. A Family Service Worker will contact you to complete this next step in the application process. After speaking with a Family Service Worker, you will receive a written notice that will inform you if your child is eligible for Head Start or Early Head Start. If your child is determined eligible, all necessary health documents must be submitted.
SHORE UP! Inc. serves children and families in high-quality early childhood development settings, and provides an array of services that address school readiness, health and nutrition, social and emotional development, mental health, family needs and so much more.
 
Parent/Guardian
 
First Name (Required): 
Last Name (Required): 
Is there another parent/guardian in the family?  Yes:       No: 
If yes, write the name of the other parent/guardian.  
Other parent/guardian First Name (Required): 
Other parent/guardian Last Name (Required): 
Date of Birth (Required): 
Gender: 
Race: 
Email Address: 
Confirm Email Address: 
What is the best phone number to reach you: 
Do you have a computer/laptop available to the family?  Yes:       No:   
Do you have internet access available to the family?  Yes:       No:   
Is your family experiencing homelessness?  Yes:       No:   
Residence Street Address: 
Apartment number: 
City: 
State:
Zip Code: 
County: 
Is mailing address different than residence address?   Yes:       No:   
If yes, write your mailing address.  
Street Address: 
Apartment number: 
City: 
State: 
Zip Code: 
County: 
Language: 
Primary Language at Home: 
Employment Status: 
Highest Grade Completed: 
Child Relationship to parent/guardian: 
Lives with Family? Yes:  Yes:       No:   
 
 FAMILY INFORMATION
 
Number of members in family: 
Number of members in household: 
Source of  family income: 
Gross annual income: 
Please check all the cash benefits that your family is currently receiving.  
Is your family receiving Supplemental Security Income (SSI)?  Yes:       No:   
Is your family receiving kinship care income?  Yes:       No:   
Is your family receiving foster care supplement?  Yes:       No:   
Is your family receiving Temporary Cash Assistance (TCA)?  Yes:       No:   
 Is your family receiving Food Stamps (TANF)?  Yes:       No:   
 Is your family receiving any other cash benefits not mentioned above?  Yes:       No:   
If yes, please specify the other cash benefits: 
Is at least one parent/guardian an active member of the United States military?  Yes:       No:   
 Is at least one parent/guardian a veteran of the United States military?  Yes:       No:   
 
Child (Application)
 
First Name (Required): 
Last Name (Required): 
Suffix: 
Nick Name: 
Date of Birth (Required): 
Gender: 
Race: 
Language: 
Does your child have health insurance?  Yes:       No:   
Does your child have dental coverage?  Yes:       No:   
Does your child have a confirmed disability?  Yes:       No:   
If yes, specify the disability type: 
Are there any siblings in the family?  Yes:       No:   
If yes, how many: 
Is there anything else you want to tell us about your child?