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:
Choose one
Female
Male
Race:
Choose one
Black or African American
Caucasian
Hispanic
Asian
Native American
American Native & White
Haitian
Pakistani
Unspecified
Pacific Islander
Latino
Native Hawaiian
Alaskan Native
Asian & White
Black & White
Choose not to Respond
Other Multi-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:
Choose one
Maryland
Delaware
Virginia
Zip Code:
County:
Choose one
Wicomico
Somerset
Worcester
Kent
Queen Annes
Talbot
Dorchester
Caroline
Other
Allegany
Anne Arundel
Baltimore City
Baltimore
Calvert
Carroll
Cecil
Charles
Frederick
Garrett
Harford
Howard
Montgomery
Prince Georges
St Marys
Washington
Sussex
Kent
New Castle
Fairfax
King George
Prince William
Loudoun
Is mailing address different than residence address?
Yes:
No:
If yes, write your mailing address.
Street Address:
Apartment number:
City:
State:
Choose one
Maryland
Delaware
Virginia
Zip Code:
County:
Choose one
Wicomico
Somerset
Worcester
Kent
Queen Annes
Talbot
Dorchester
Caroline
Other
Allegany
Anne Arundel
Baltimore City
Baltimore
Calvert
Carroll
Cecil
Charles
Frederick
Garrett
Harford
Howard
Montgomery
Prince Georges
St Marys
Washington
Sussex
Kent
New Castle
Fairfax
King George
Prince William
Loudoun
Language:
Choose one
English
Spanish
French
Native American
Asian Language
Other
Korean
Japanese
Haitian
Hmong
Chinese
Vietnamese
Cambodian
Swahili
Wolof
Tagolog
Croatian
German
Italian
Portuguese
Yiddish
Arabic
Bengali
Hebrew
Hindi
Urdu
Creole
Patois
Fijian
Pauluan
Primary Language at Home:
Choose one
English
Spanish
French
Native American
Asian Language
Other
Korean
Japanese
Haitian
Hmong
Chinese
Vietnamese
Cambodian
Swahili
Wolof
Tagolog
Croatian
German
Italian
Portuguese
Yiddish
Arabic
Bengali
Hebrew
Hindi
Urdu
Creole
Patois
Fijian
Pauluan
Employment Status:
Choose one
Full-Time (Over 35 hours/week)
Part-Time (Under 35 hours/week)
Seasonally Employed
Unemployed
Retired or Disabled
Job Training School
Employed and in school / training
Not Applicable
Highest Grade Completed:
Choose one
Grade 8 or less (0-8)
Grades 9-12 (non-graduate)
High School Graduate
Some College or Advanced Training
College Degree or Trade School Certificate
High School Dropout
ABE
Graduate Degree
Associate Degree
Baccalaureate Degree
Master's Degree
Child Development Associate (CDA)
Certification/License
HS-Associate Degree, ECE/Related
HS-Enrolled in Baccalaureate Degree, ECE/Related
HS-Baccalaureate Degree, ECE/Related
HS-Graduate Degree, ECE/Related
HS-CDA Credential or State Equivalent
HS-Enrolled in an ECE/Related Degree
HS-Without CDA or Equivalent Training
HS-CDA Equivalent Training
HS-Enrolled in CDA Training
GED
Post College Graduate
Currently in Job Training/School
Advanced Degree
Child Relationship to parent/guardian:
Choose one
Head of Household
Head of Family
Spouse
Mother
Father
Son
Daughter
Grandfather
Grandmother
Uncle
Aunt
Cousin
Other
< Unknown >
Grandchild
Foster Care
Kinship
Lives with Family? Yes:
Yes:
No:
FAMILY INFORMATION
Number of members in family:
Number of members in household:
Source of family income:
Choose one
Employment
Self-Employment
Wages Received Under the Job Training Partnership Act (JTPA)
Unemployment Insurance Benefits
TCA
General Public Assistance
Social Security
Veteran Administration Benefits
Child Support
Worker's Compensation Insurance
Armed Forces Dependent Alliance
Criminal Injuries Compensation
Dividends, Interest, Annuities Trust, Estate Rental or Royalty Income from Roomer or Boarder
Pension, Retirement, Mine Workers Benefit
None
Alimony
Private Retirement
SSI
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:
Choose one
II
III
IV
Jr
Sr
Nick Name:
Date of Birth (Required):
Gender:
Choose one
Female
Male
Race:
Choose one
Black or African American
Caucasian
Hispanic
Asian
Native American
American Native & White
Haitian
Pakistani
Unspecified
Pacific Islander
Latino
Native Hawaiian
Alaskan Native
Asian & White
Black & White
Choose not to Respond
Other Multi-Race
Language:
Choose one
English
Spanish
French
Native American
Asian Language
Other
Korean
Japanese
Haitian
Hmong
Chinese
Vietnamese
Cambodian
Swahili
Wolof
Tagolog
Croatian
German
Italian
Portuguese
Yiddish
Arabic
Bengali
Hebrew
Hindi
Urdu
Creole
Patois
Fijian
Pauluan
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:
Choose one
Blindness/Visual Impairment
Deafness/Hearing Impairment
Emotional Behavioral Disorders
(Specific) Learning Disability
Mental Retardation
Autism
Health of Developmental Impairment
Physical Disability (Orthopedic)
Speech or Language Impairment
Traumatic Brain Injury
Multi-Disability/Other
Developmental Delay
None
Orthopedic
Deaf-Blind
Intellectual Disabilities
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?