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.

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Pregnancy to Preschool Intake Form

School Year:
Please select the school year you are submitting this pregnancy to preschool intake form for:
2021-2022: Current school year, ending in June 2022.
2022-2023: Next school year, beginning in September 2022.
Child's Information
Child's Name:

Date of Birth:
Gender: Male
Female
Ethnicity:
(check all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic of any race
Unknown
Address:

County:
Program Preferences:

Parent/Guardian Information
Parent/Guardian 1:

Parent/Guardian 2:

Providing your email address will ensure regular communication about preschool.

Phone Number:

() -

Alternate Number:

() -

How would you prefer to be contacted?
 Phone
 Email
 Text
Marital Status:
Single
Married
Divorced
Widow
Separated
Child Lives With (Primary Physical Custody):
(check all that apply)
Mother
Father
Both Parents
Joint Custody-Physical
Joint Custody Legal
Foster Care
Legal Guardian
Grandparent
Other:
Number of immediate family members living in the household:

Parent/Guardian 1 Income Information
Parent/Guardian 1 Gross Income:
Income before taxes or other deductions. Verification of income will be required.

Choose the period the above wage represents:

Any Additional Income:
(ex. Child support, rental income, etc)

Choose the period the above wage represents:

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:
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
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)
DHHS Child Care Assistance
DHHS Financial
DHHS Food Assistance
Medicaid
Women, Infants and Children (WIC)
I am pregnant and/or have a child birth to 3 and would like information on birth to 3 program options.

Yes   No

How did you learn about us?:
 Advertisement
 Community Organization
 Event
 Friend/Family Member
 Teacher/Education Professional
 Website
 Other:
Child Care (Daycare) Information
Child Care (Daycare) Provider:

Child Care (Daycare) Address:

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