Preschool Enrollment Form

Clinton County Pregnancy to Preschool Partnership

Preschool Picture

WELCOME to the Clinton County Pregnancy to Preschool Partnership!  If you are pregnant and/or have children under age 5, you have come to the right place!

By filling out this form, we can help you enroll in home visiting and/or preschool programs.  We want to support your family in finding the best programs possible.

Please fill out the form below or call 855-MI4-PREK (855-644-7735).  Once you submit the form, you will get an email response (if you provided us with an email address).

If you are filling out this form and pregnant, please enter "Baby" for the First Name, "NA" for the Middle Name and enter the Last Name. Also, please put the delivery due date in the Date of Birth field.  If you do not know the gender, select either male or female and we will correct the information later, if necessary.

In addition, if you have children 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 Clinton County Early On program may be right for you. Please follow this link to find out more information: click here

Please review the following links before submitting your child's intake form.

  1. Program Information, click here
  2. Frequently Asked Questions, click here

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.

 

To join Clinton County RESA's Early Childhood Listserv, click here.

Like us on Facebook at Clinton Great Start, click here.

For information on Playgroups, click here.

For information on joining the Great Start Parent Coalition, click here.

 

CCRESA Logo


Pregnancy to Preschool Interest Form

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:

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
Marital Status:
Single
Married
Divorced
Widow
Separated
Child Lives With:
(check all that apply)
Mother
Father
Both Parents
Joint Custody-Physical
Joint Custody Legal
Foster Care
Legal Guardian
Grandparent
Other:
Number of people 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:

Parent/Guardian 1 Income Source:
(check all that apply)
Working
Child Support
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (Family Independence Program)
Other:
Is this more than stated on Parent/Guardian 1's 2019 income tax return?

Yes   No

Have there been any income changes for either Parent/Guardian in the last 6-12 months?
(i.e., unemployment, wage increase/decrease, etc.)

Yes   No

Additional Information
Is there additional information that you can share about your child/family?
Rollover highlighted text for definitions.
Abuse/NeglectDomestic, sexual, or physical abuse of child or parent; child neglect issues. Child Protective Services report.

Abuse of alcohol, prescription or non-prescription (inhalants, cough syrup, methamphetamine, etc.) drugs by family members or in the home.
Challenging BehaviorChild has been expelled from preschool or child care center.
Diag. Overactive
Disability/Developmental DelayChild is eligible for special education services or child's developmental progress is less than that expected for his/her chronological age, or chronic health issues cause development or learning problems.
Environmental Risk
  • Parental loss due to death, divorce,incarceration, military service, or absence;
  • sibling issues;
  • teen parent (not age 20 when first child born);
  • family is homeless or without stable housing;
  • residence in a high-risk neighborhood (area of high poverty, high crime, with limited access to critical community services); or
  • prenatal or postnatal exposure to toxic substances known to cause learning or developmental delays.

Health
Hearing
High Lead
Non-English SpeakingEnglish is not spoken in the child's home; English is not the child's first language.
Orthopedic
Parent EducationParent has not graduated from high school or is illiterate
Speech/Language
Vision
Other:
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

Has your child been referred/involved in:
(check all that apply)
Early Childhood Special Education
Early Head Start
Early On
Head Start
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:
Childcare Information
Childcare Provider:

Childcare Address:

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