Clinton County Pregnancy to Preschool Partnership

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! We want to support your family in finding the best programs possible. Please fill out the intake application below or call 855-MI4-PREK (855-644-7735). Once you submit the intake application, you will receive an auto-generated email response if an email address is provided.

If you are filling out this form and are 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.

Program Information, click here
Frequently Asked Questions, click here

After reviewing your intake application and family information, you may be referred to one or more of the following programs: Women, Infants and Children (WIC); the Maternal Infant Health Program (MIHP); Early Head Start; Early On; Parent-Infant/Young Child Program; Head Start or the Great Start Readiness Program (GSRP).

By submitting your intake application, you give permission for Clinton Great Start to share your intake application with participating schools and/or local agency partners that are part of the Pregnancy to Preschool Partnership. We may also add your email address to Clinton County RESA's Early Childhood listserv mailing list. Please contact Cindy at pline_c@ccresa.org or (989) 224-6831, ext. 2153 if you have questions or do not want to be added to the listserv.

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.

For information on Playgroups, click here.

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

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

To follow us on Instagram: click here

Pregnancy to Preschool Interest Form

Child's Name:

First Name:

Middle Name:

Last Name:

Date of Birth:

Gender: Male
Female

Ethnicity:

(check all that apply)

Address:

Street Address:

Street Address 2:

City:

Zip Code:

Parent/Guardian Information

Parent/Guardian 1:

First Name:

Last Name:

Parent/Guardian 2:

First Name:

Last Name:

Providing your email address will ensure regular communication about preschool.

Email Address:

Alternate Email:

Phone Number:

() -

Alternate Number:

() -

How would you prefer to be contacted?

Phone
Email

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:

Is this more than stated on Parent/Guardian 1's 2021 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.

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)

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?:

Child Care (Daycare) Information

Child Care (Daycare) Provider:

Name:

Child Care (Daycare) Address:

Street Address:

Street Address 2:

City:

State:

Zip Code:

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