Welcome to the Bay-Arenac Pregnancy to Preschool Partnership

If you are currently pregnant and/or have children of ages 0-5, you've come to the right place!

We want to support you in finding the best possible programs for your family and by filling out and submitting the information below we can help you along that path.

A description of each of our early education programs can be found by clicking the “About Us” link on the green bar above.

In addition, if you have children of ages 0-3 who you feel may be experiencing a developmental delay or have an established condition that may result in a developmental delay, the Bay-Arenac ISD Early On program may be right for you. Please follow this link to find out more information: Bay-Arenac Early On

If you are filling out this form and pregnant, please enter "Baby" for the First Name and use your due date as the Birthday. If you do not know the gender, please still select either male or female and we will correct the information as necessary.

To talk with someone about more help available for your family, dial 2-1-1. It is free and available 24 hours a day, 7 days a week.

Pregnancy to Preschool Intake Form

Child's Name:

First Name:

Middle Name:

Last Name:

Date of Birth:

Gender: Male
Female

Ethnicity:

(check all that apply)

Address:

Street Address:

Apt./Lot Number:

City:

Zip Code:

County:

Program Preferences:

Preference 1:

Preference 2:

Preference 3:

Other Comments About Preferences

Parent/Guardian Information

Parent/Guardian 1:

First Name:

Last Name:

Providing your email address will ensure regular communication about preschool.

Email Address:

Phone Number:

() -

How would you prefer to be contacted?

Phone
Email
Text

Parent/Guardian 2:

First Name:

Last Name:

Email Address:

Phone Number:

() -

Address if different than child's:

Street Address:

City:

State:

Zip Code:

Marital Status:

Child Lives With (Primary Physical Custody):

(check all that apply)

Number of immediate family members living in the household:

Number of Adults:

Number of Children:

Parent/Guardian 1 Income Information

Parent/Guardian 1 Gross Income:

Income before taxes or other deductions. Verification of income will be required.

Wages: $

Choose the period the above wage represents: Weekly Bi-Weekly Monthly Annually Prior Year Income Tax Return

Any Additional Income:

(ex. Child support, rental income, etc)

Wages: $

Choose the period the above wage represents: Weekly Bi-Weekly Monthly Annually Prior Year Income Tax Return

Parent/Guardian 1 Income Source:

(check all that apply)

Working
Child Support
Supplemental Security Income (SSI)

Temporary Assistance for Needy Families (Family Independence Program)
Supplemental Nutrition Assistance Program (SNAP)/Food Assistance Program (FAP)
Other:

Are you paying child support to Parent/Guardian 2?

Yes No

Is Parent/Guardian 1 enrolled in school and/or a job training program?

Yes No

Additional Information

Is there additional information that you can share about your child/family?

Rollover highlighted text for definitions.

Has your child been referred/involved in:

(check all that apply)

Early Childhood Special Education
Early Head Start
Early On
Head Start

If your child is currently receiving Early On or special education services, please select from the following:

Individualized Family Service Plan (IFSP): Early On
Individualized Education Program (IEP): Special Education
No

Explain any concerns checked:

(i.e., evaluations, specialist, parent concern, lead count, primary language)

Is your child's current address a temporary living arrangement?

Yes No

Do you have reliable transportation?:

(for planning purposes only)

Yes No

Current services received by family:

(check all that apply)

I am pregnant and/or have a child birth to 3 and would like information on birth to 3 program options.

Yes No

Is there anyone else that you would like to authorize the district or program to discuss enrollment with?

Yes No

How did you learn about us?:

I understand and agree to having my information shared with local Head Start, Great Start Readiness Program, and Home Visiting Program providers.