Online Enrollment Application | MHA Infant & Toddler Program

Prefer to complete a fillable PDF instead? View the PDF application and follow the step-by-step instructions to complete and submit it.

Complete the Fillable PDF Application

1Child Information, Parent/Guardian Information, and Exchangeable Release of Information

2Family Information and Financial Assistance Disclosure

3Miscellaneous Information, Text Messaging, and Media Release

4Disability Disclosure & Certification

Company

This field is for validation purposes and should be left unchanged.

Child Information

Child's Full Name(Required)

First Last

DOB(Required)

Gender(Required)

Ethnicity(Required)

Birth Weight(Required)

Pounds (lbs)

Ounces (oz)

Weeks Premature(Required)

Please enter a number from 0 to 50.

Residing Segment(Required)

Enrolled member of a Federally Recognized Tribe?(Required)

Yes

Tribal Affiliation(Required)

Enrollment Number(Required)

Is child adopted?(Required)

Yes

Is child currently in foster care?(Required)

Yes

List case manager (if applicable)

Referral Source

Health Insurance

Parent/Guardian Information

Parent/Guardian Full Name(Required)

First Last

DOB(Required)

Parent/Guardian Phone(Required)

Parent/Guardian Email(Required)

Parent/Guardian Full Name

First Last

DOB

Parent/Guardian Phone

Parent/Guardian Email

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Physical Address Same As Mailing Address

Physical Address is same as Mailing Address

Physical Address

Street Address Address Line 2 City State ZIP Code

Best Way to Contact(Required)

Call

Text

Best Time to Contact(Required)

Exchangeable Release of Information

Please enter your initials for the following statment(s):

I hereby authorize the MHA Infant and Toddler Program, under the Three Affiliated Tribes, to exchange verbal and written information regarding my child’s evaluations, programming, health records, developmental progress, enrollment, and services with the Three Affiliated Tribes Enrollment Department, TAT Head Start, and therapy/service agencies working with my child. I give consent to the Infant & Toddler Program to conduct developmental screenings to determine any concerns or needs with my child’s development.(Required)

Family Information

Please Check that Apply

TANF

Medicaid

EBT/Commodities

General Assistance

WIC

First Steps

Indian Health Services

Other

If you checked Other, please specify

Occupation Status(Required)

Employed

Unemployed

Highest Level of Education(Required)

Financial Assistance Disclosure

To qualify for financial assistance your child must fit into one of the following categories:

Tier 1- Life Threatening, Unforseen Emergencies, or Specialty Appointments
Tier 2- Diagnosed Disability
Tier 3- Developmentally Delay
Tier 4- Disabled Child in the Womb

Enter your initials for each statement below.

I understand that if I am receiving financial assistance from the Infant and Toddler Program, I am not eligible to request additional assistance from Grants & Donations, TAT Head Start, the Chairman’s Office, or any Segment Offices for the same appointment or hospital stay.(Required)

I understand that the Infant and Toddler Program does not provide financial assistance for in‐home or virtual appointments.(Required)

I understand that reimbursement checks from the Infant and Toddler Program typically require 2–3 business days to process; however, this timeframe is not guaranteed. I will be notified by phone when the reimbursement check is ready for pickup.(Required)

I understand that reimbursement checks are generally issued after the appointment has occurred, and that verification from the provider confirming that my child attended the appointment is required before a reimbursement can be processed.(Required)

Please Check All That Apply

Miscellaneous Family Info

Teen parent

Baby born with a positive toxic screen (drugs)

Child with a disability

Chronic health condition

Low educational attainment

Low income (eligible for WIC, Food Stamps, TANF, LIHEAP, GA, etc.)

Recent immigrant or refugee family (foreign born)

Substance abuse (parent had used or currently using illegal substances)

Court appointed legal guardians and/or foster parents

Homeless or unstable housing

Incarcerated parents

Very low birth weight/premie (under 3.3 lbs.)

Death in immediate family (child, parent, sibling)

Domestic violence

Child abuse or neglect

Military family

On Individual Education Plan (IEP) or Individual Family Service Plan (IFSP)

Receiving financial assistance from any other tribal or federal funded program for appointments

Text Messaging

I would like to sign up for ChildPlus text messaging from Infant and Toddler Staff or when there is an upcoming event.(Required)

Yes

Media Release

I give consent for photographs, videos, and/or like materials, in which my child may appear to be used in any promotion materials.(Required)

Yes

Disability Disclosure

The information you provide will help us connect you with the appropriate resources for your child. Please check the appropriate box if your child has been identified or is suspected of having any of the following:

Disability Inventory

Disability

Identified

Suspected

Date:

Evaluated by:

No Disabilities To Report

Please check box if parent/guardian reports no disibility at this time.

I certify that my statements on this application and any attachments to it are true, complete, and correct to the best of my knowledge and belief and are made in good faith.

Legal Parent/Guardian Signature(Required)

Your Name
Your Name
Your Name

Date(Required)