Pregnant Mother Application

All of the information in this document will be treated confidentially by HCCADC staff.

This form is to be used for pregnant mothers who may be eligible for the Early Head Start Program.

This application does not guarantee acceptance into the programs offered by HCCADC. These programs have income eligibility requirements, which must be verified before a participant can be accepted. After submitting the application, you will be contacted by an HCCADC staff member who will let you know if you may qualify, answer any questions that you may have, and discuss the next steps with you.

The form does not allow you to go back and edit it, please proofread it before submitting

First Name *

Middle Name *

Last Name *

Mailing Address *

City *

State *

Zip Code *

County *

Phone *

Trimester *

Family Size *

Number of people supported by the above income

Directions

Please provide directors to your home and the physical address if different from the mailing address. If you home sits back off the road please explain how to get there.

Type Name *

By typing my name, I am certifiying that the information have provided is accurate; I understand this information will be used to determine my eligibility in HCCADC programs; I understand that HCCADC has income eligibility requirements and priorities when enrolling participants.