Preschool Enrollment Form

Welcome to Clinton County Preschool

Preschool Picture

Are you interested in free preschool for a child who is 3 to 5 years old?  Many children qualify!  If you think your child might qualify, complete the form below or call (855) 644-PreK and someone will be in touch with you about the free preschool opportunities that are available to residents of Clinton County. 

Please be aware that according to new state guidelines, all children must be 3 years old on or before September 1st to be eligible for Head Start. Children must be 4 years old on or before September 1st to be eligible for GSRP, if your child is 5 years old by September 1st they are not eligible for these programs.

Visit About Us to learn what makes a child eligible for free preschool.

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Preschool Interest Form

First Name:
Middle Name:
Last Name:

Male Female

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic of any race
Unknown


City:
State:
Zip:

Parent/Guardian Information

First Name:
Last Name:

First Name:
Last Name:

Providing your email address will ensure regular communication about preschool.

() -

() -

Marital Status:
Single
Married
Divorced
Widow
Separated

Child Lives With:
Mother
Father
Both Parents
Joint Custody-Physical
Joint Custody Legal
Foster Care
Legal Guardian
Grandparent
Other:

Number of adults living in household:
Number of children living in household:
Parent/Guardian 1 Income Information
Parent/Guardian 1 Gross Income:
Verification of income will be required.

$ Weekly Bi-Weekly Monthly Annually

Parent/Guardian 1 Income Source:
Working
Child Support
Supplemental Security Income (SSI)
Other:

Is this more than stated on Parent/Guardian 1's 2015 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.

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 Ed.
Early Head Start
Early On
Head Start

Current services received by family:
(check all that apply)
DHS Child Care Assistance
DHS Financial
DHS Food Assistance
Medicaid

I have a child birth to 3 and would like information on birth to 3 program options.

Yes   No

Childcare Information


City:
State:
Zip:

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