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Services
Research
Events
About Us
Donate
Get Involved
Blog
Contact

Step 1 of 2

50%

Personal Information
Where did you hear about us?
How many people are dependent on your family income?*
Hidden
Number of Dependants Outside of your Household
Please do not duplicate persons
Name*
First Last
Name of Child
First Last
Child's Date of Birth
MM slash DD slash YYYY
Name of Child 2
First Last
Child's Date of Birth 2
MM slash DD slash YYYY
Name of Child 3
First Last
Child's Date of Birth 3
MM slash DD slash YYYY
Name of Child 4
First Last
Child's Date of Birth 4
MM slash DD slash YYYY
Name of Child 5
First Last
Child's Date of Birth 5
MM slash DD slash YYYY
Name of Child 6
First Last
Child's Date of Birth 6
MM slash DD slash YYYY
Name of Child 7
First Last
Child's Date of Birth 7
MM slash DD slash YYYY
Name of Child 8
First Last
Child's Date of Birth 8
MM slash DD slash YYYY
Name of Child 9
First Last
Child's Date of Birth 9
MM slash DD slash YYYY
Name of Child 10
First Last
Child's Date of Birth 10
MM slash DD slash YYYY
Name of Child 11
First Last
Child's Date of Birth 11
MM slash DD slash YYYY
Name of Child 12
First Last
Child's Date of Birth 12
MM slash DD slash YYYY
Income Calculation Fields
If you have Pay Stubs, what is the pay frequency?
Yearly Salary
1040, or other
Pay Stub Amount Weekly
Pay Stub Amount Every Two Weeks
Pay Stub Amount Bi-Montly
Estimated Yearly Income if Pay Stub is Weekly
Estimated Yearly Income if Pay Stub is Every Two Weeks
Estimated Yearly Income if Pay Stub is Bi-Monthly
Other Income Types - All Fields Are Calculated as Annual Amounts
Other Income Types
- Tips
- Self-Employment
- Social Security
- Unemployment
- Disability
- Survivor Benefits
- Spousal Support
- Child Support
- Pension
- Indian Game Disbursements
- Foster Care
Tips
Self-Employment
Must be notorized
Social Security Income
Unemployment
Disability
Survivor Benefits
Spousal Support
Child Support
Pension
Indian Game Disbursements
Foster Care
Income Total
This Field is Calculated Based on the Above Fields
Screening Eligibility Forms Collected
Option 1: Income Verifications Forms Received
- 1040
- Notarized Self-Employment
- 2 Pay Stubs
- Other
If Other
Option 2: Government Assistance
- Cash Assistance
- Nutrition Assistance
- Housing
- WIC
- Other
current award letter with all pages required
If Other
Hidden
Calculated Addition to Base FPL
Hidden
100% of FPL
Notes:

Save and Continue Later

Your FPL Percentage
Early Learning Family Locator Service
Nearest Elementary School
Hours of Operation Needed
Mode of transportation available?
For Other Considerations, Please Check All that Apply
Other Considerations
- Nurse on Staff
- IEP
- Other
If Other
Other Considerations 2
- Mixed Age Group
- Bilingual
- Year-Round
- School-Year Round
- Meals Provided at Site
- Snacks Provided at Site
- Other
Extra-curricular Notes
Other
Type
- Faith Based
- Montessori Based
- Waldorf Based
- No Preference
Possible Eligibilities
You may be eligible for Head Start. Would you like to consider this program?
You may be eligible for Head Start. Would you like to consider this program?
You may be eligible for Head Start. Would you like to consider this program?
You may be eligible for DES. Would you like to consider this program?
You may be eligible for Quality First Scholarship. Would you like to consider this program?
You may be eligible for Elevate Pre-K. Would you like to consider this program?
If Eligible but Not Interested, Please Indicate Why:
Other
Are any children currently enrolled in pre-school?
Which School?
Summary

Save and Continue Later

Δ

Google Map of Resources

Child Care Resources and Referral Tool

ADHS List of Programs

NACOG Head Start

Quality First Parents

Please Note that this is a tool for us to use to determine if you are possibly eligible for a service, but does not guarantee eligibility.

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PHOENIX OFFICE
777 E. Thomas Road, Suite 200
Phoenix, AZ 85014
PHONE: (480) 829-0500

FLAGSTAFF OFFICE
2708 N. 4th Street, Suite C1
Flagstaff, AZ 86004
PHONE: (928) 714-1716

LAS VEGAS OFFICE
1771 E. Flamingo Road, Suite 200B
Las Vegas, NV 89119
PHONE: (725) 255-4617

RENO OFFICE
961 Matley Lane, Suite 110
Reno, NV 89502
PHONE: (775) 256-7485

Copyright 2021 Candelen.

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