Early Childhood Programs

CHIPPEWA - LUCE - MACKINAC COMMUNITY ACTION HUMAN RESOURCE AUTHORITY, INC. 524 ASHMUN STREET SAULT STE. MARIE, MICHIGAN 49783 PHONE (906) 632-3363

CHIPPEWA LUCE MACKINAC COMMUNITY ACTION AGENCY

Early Childhood Programs Enrollment Information

Thank you for requesting an enrollment application for the Community Action Agency's Early Childhood Program. We offer early childhood programs for pregnant women and children 0-5 years of age. These programs are funded by sources which have different requirements for eligibility. Early Head Start Program Early Head Start is a federally funded program with eligibility criteria based on age, family income and other categories set forth by the program ensuring that families with the highest need receive priority. The program serves pregnant women and children ages 0 to 3 years old in either center based or home-based program options. Full day/full year center-based services are provided in Sault Ste. Marie, Newberry and St. Ignace. Home-based services are provided in Sault Ste. Marie and Kinross. Meals and snacks are provided. Head Start Program Head Start is a federally funded program with eligibility criteria based on age, family income and other categories set forth by the program ensuring that families with the highest need receive priority. Children must be at least 3 years old on or before September 1st of the current school year. Centers located in Brimley, Cedarville, Drummond Island, Kinross, Newberry and Sault Ste. Marie. Classrooms meet 7 hours and 15 minutes per day, Monday through Thursday. Meals and snacks are provided. Strong Beginnings Program Strong Beginnings is funded through MiLEAP. Children must be 3 years old on or before December 1st with priority given to children turning 3 on or before September 1st. Income limits up to 250% of poverty. Classrooms located at the Sault Early Learning Center in Sault Ste. Marie and in Rudyard Schools. Classrooms meet for 7 hours per day, Monday through Thursday. Meals and snacks are provided. Great Start Readiness Program The Great Start Readiness Program is funded through MiLEAP. Children must be 4 years old on or before December 1st with priority given to children turning 4 on or before September 1st. Income limits have been lifted for GSRP with priority given to families with incomes at or below 400% of poverty. Classrooms located at the Ronald Calery Community Center and the Sault Early Learning Center with limited slots in Brimley and Cedarville. Days and times are dependent upon location. Meals and snacks are provided. Income Information Income information is confidential and will only be used for eligibility purposes. All the programs operated through the Community Action Agency have a variety of income guidelines. The Early Childhood programs must determine income for the immediate 12 months prior to submission or the previous tax year. Income verification must include all current W-2 forms, Federal 1040 tax returns, statements from employers, last 12 months child support if receiving and/or verification of any other form of income. If your family receives Supplemental Security Income (SSI), cash assistance (FIP) or the Supplemental Nutrition Assistance Program (SNAP) from the Department of Health and Human Services they are automatically income eligible. Verification must be submitted with the application. If applicant is a foster child, they are automatically eligible for the program. Verification in the form of current court documents or a letter from the child's case worker must be submitted with the application. Unhoused families are automatically eligible. Verification needed will be determined upon application submission. Enrollment Application Please complete all sections of the enrollment application. This information is used for enrollment and placement purposes. Attach a copy of your child's immunization record, birth certificate, and proof of income to the enrollment form. If your child has a current IEP or IFSP a copy is also required. Your application will not be eligible for enrollment if all required documents have not be submitted. Return the completed application to the CLM Community Action Agency, 524 Ashmun Street, Sault Ste. Marie, MI 49783 or by emailing to sfeltis@clmcaa.com. If you have questions regarding program requirements or the enrollment process, please contact 906-632-3363.

Equal Opportunity Employer and Provider imunity Development Human Resources Transportation Head Start/Preschool Senior Citizens Housing EnergyWeatherization

School Year Applying For

Program Requested:

Early Head Start - Center Based or Home BasedHead StartStrong BeginningsGSRP

Center/Location Preference: (Preference cannot be guaranteed)

1st

2nd

Applicant Information: Legal Name

Last

First

MI

Date of Birth

Date

Preferred Name/Nick Name

Gender

MaleFemale

Place of Birth (city, state)

Race

Other

Hispanic

YesNo

Home Address

Street

Street Address Line 2

City

Zip CodeCounty

County

Mailing Address

Street

Street Address Line 2

City

Zip CodeCounty

County

Primary Phone

CellHome

Secondary Phone

CellHome

Work Phone

Message Phone

May we text you at the listed cell numbers?

YesNo

Child's Primary Language:

EnglishSpanishOther

Other

Parent Primary Language

Do you require an Interpreter?

YesNo

Parent/Guardian Information:

Date of Birth

Relationship to Applicant

Live with Applicant

YesNo

Employed

YesNoFullPart

Attending School/College

YesNoPartFull

Email Address:

May we email you?

YesNo

Name:

Date of Birth

Relationship to Applicant

Live with Applicant

YesNo

Employed

YesNoFullPart

Attending School/College

YesNoFullPart

Email Address:

May we email you?

YesNo

If you are not the biological or legal step-parent of the child, do you have court-appointed custody/guardianship? If Yes, please attach legal documentation.

YesNo

Name:

Date of Birth

Relationship to Applicant

Live in Household at Least 50% of the Time

YesNo

Name

Date of Birth

Relationship to Applicant

Live in Household at Least 50% of the Time

YesNo

Name

Date of Birth

Relationship to Applicant

Live in Household at Least 50% of the Time

YesNo

Name

Date of Birth

Date

Relationship to Applicant

Live in Household at Least 50% of the Time

YesNo

Number of Parents in the Household (Related by blood, marriage or adoption)

Number of People in Family (All people living in home supported by parent/guardian income)

Number of People Living in Household (All household members regardless of relation)

Income Reported on Most Recent Federal 1040 Tax Return/W2s

All Non-Taxable Income Received for Same Tax Year (Child Support, Social Security, Disability Income, etc.)

Birth Certificate/Income

Do you or a member of your immediate household receive SSI?

YesNo

Do you receive SNAP (Supplemental Nutrition Assistance Program)?

YesNo

Do you receive FIP (Cash Assistance)?

YesNo

If you answered Yes to SSI, SNAP or FIP please submit verification of current receipt for eligibility purposes. If more than one is received, Only verification of one program is necessary.

Is applicant a foster child? If yes, please submit verification of foster care status.

YesNo

Is your family currently unhoused or in a temporary living arrangement due to loss of housing or economic hardship?

YesNo

If Yes, where is child currently residing? (Please check all that apply)

Child has active IEP and is receiving special education services.

YesNo

If yes, please provide school/agency.

Child has an IFSP and receives Early On Services

YesNo

Child has health issues that could result in a developmental delay or learning difficulty.

YesNo

If yes, provider name/specialist

Child has received a low score on a developmental screening.

YesNo

If yes, has child been referred for special education services?

YesNo

Child’s behavior has repeatedly prevented him/her from participating in a group setting such as preschool, church, or daycare.

YesNo

A mental health professional has referred child for services

YesNo

One or both parents did not graduate from high school or have difficulty reading or cannot read

YesNo

Child has been abused/neglected or there is/has been CPS involvement with your family

YesNo

There has been domestic violence/spousal abuse of parent or sibling

YesNo

There has been substance misuse by family members in the home (alcohol, recreational drugs, prescription drugs or non-prescription drugs)

YesNo

Parent/Guardian is currently in substance misuse or mental health treatment facility or program

YesNo

Parent is current active duty or deployed in the military

YesNo

Parent is or has been incarcerated

YesNo

Parent suffers from chronic illness/disability (physical, emotional and/or mental)

YesNo

Single parent or parents have divorced or separated

YesNo

If yes, is there frequent changes in custody?

YesNo

Grandparent or other relative is raising child

YesNo

Home is unsafe, crowded, lacks utilities, located in an unsafe neighborhood due to high crime, drug use, violence or there is no space for child to play

YesNo

Child was prenatally exposed to drugs/alcohol

YesNo

If yes, has child been diagnosed with Fetal Alcohol Syndrome?

YesNo

Parent/Guardian Signature

Date

How did you hear about our program?

Early Childhood Programs

CLM COMMUNITY ACTION EARLY CHILDHOOD PROGRAM - ENROLLMENT APPLICATION

Please list any additional family members living in the household that are supported by the income of the applicant’s parent/guardian (siblings, step-siblings, grandparents, etc.)