Collaborative Preschool Application

Family Income Information: Eligibility is based on child's age, family income, child's need, and available openings *

Income Notes (wage increase/decrease, recently started working, etc.) Please explain other sources of income not listed above:

Marital Status:

Highest level of education completed:

Has your child ever been exposed to a toxic substance?

If yes, what substance

In the past 2 years have you or members of your household:

	Yes	No
Experienced difficulty obtaining medical services?
Used the Emergency Room?
Received a shut-off notice from a utility company?
Been homeless?
Been without heat?
Used a food pantry?
Were you under 20 yrs old when your first child was born?
Have you live in more than 2 homes in the past 3 yrs?
Do you live in a high risk area (high poverty, crime or limited access to critical services)?
Has your child suffered a parental loss due to death, divorce, incarceration, military service or absence?
Has your ever been expelled from a child care center?
Has anyone in your home been a victim of physical/domestic/sexual abuse or neglect?

List any additional family members living in the household with the applicant child:

Total number of family members living in the home:

including applicant child

How did you hear about your local preschool program?

This is an application only and does not guarantee your child will be enrolled into an early childhood program. The collaborative recruitment committee will review your child's application and determine the program for which your family is most eligible. Eligibility is based on a child's age, family income, child's needs, and available openings. Documentation is required. Not all program options are available in all areas. Should you be interested in a particular program, please indicate that program below so parent preference may be considered. Local protocol will be followed regarding specific program placement.

Program Preference (not guaranteed)

I authorize the release of this information and educational records to be shared between the EightCAP, Inc. Collaborative Recruitment Committee, the Great Start Readiness Preschool Program, local school districts, local Intermediate School District and the Head Start Program in the county in which I reside. My signature verifies that the above information is correct and true to the best of my knowledge. Please use your mouse or finger to sign below.

Clear

Signature Date

Date

For more information, call 1 866-754-9315 or deniseb@8cap.org

Michigan Relay Center: 1 800 649-3777 (Voice & TDD)

Gratiot and Isabella County apply online at: www.michiganpreschool.org

State and federally funded programs will not discriminate against anyone because of race, color, national origin, sex, age or disability. These materials were funded in whole or in part under a grant awarded by the Michigan Department of Education.

	Yes	No
Does your child have an up to date well child exam?
Are you child's immunizations up to date?
Is this child in a foster care placement?
Are you homeless (lack of a fixed, regular and adequate nighttime residence)?
Does your family receive SNAP (Supplemental Nutrition Assistance Program) benefit?