InterMountain ESD
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Blue Mountain Kids

Application for Early Learning Supports


This is a universal application that will identify programs your family is potentially eligible for. You will receive a follow up call to discuss options and referrals.

Complete this form for the children prenatal through 5 yrs old (preschool) that you would like to apply for services for.

General Information

Communities where interested in receiving services (check all that apply) *
Services of interest (check all that apply) *
Are you currently pregnant?

Child Information

This application is for children Prenatal through 5 yrs old (preschool age)

Child #1

Provide date of birth if the child has been born

If child has not been born provide the expected date of delivery

Gender
Race/Ethnicity (check all that apply)
Primary Language
Do you have any concern in the following areas? (check all that apply)
Relationship to child
What percentage of time does the child live with you?

Primary Parent/Guardian/Caregiver Information

Primary Parent/Guardian/Caregiver

If you do not have a phone put (999) 999-9999

Race/Ethnicity (check all that apply) *
How do you prefer to be contacted? *
Language you prefer to be contacted in *
Employment status *
Is 51% of your employment in agriculture?

Agriculture includes: Any activity related to crop production, including soil preparation, planting, cultivating, crop protection or harvesting, preparing crops for market, irrigation work, etc.

CHECK IF there is another parent/caregiver who lives in a separate household and provides financial support?

Primary Household Information

Insurance status (check all that apply) *

Has anyone in your household experienced ANY of the following:

Violence, criminal behavior, substance abuse, marital/family relationship difficulties, mental health issues, unstable employment, physical disabilities, learning disabilities or serious health issues

Is you family experiencing any of the following housing situations?

Shared housing, living in a motel, campground, couch surfing, car/vehicle, outside/park or public spaces
Is anyone in the household receiving any of the following services? (check all that apply)

Consent from Primary Parent/Guardian/Caregiver

I give consent for the information on this form to be shared between entities and programs involved in regional early learning services and for those programs to contact me (check all that you give consent for): *
I give consent for the following entities and programs to release information about current and past services to the Blue Mountain Early Learning Hub (check all that you give consent for):
How did you hear about us? (check all that apply)