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. 

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 December 1st to be eligible for GSRP, if your child is 5 years old by September 1st they are not eligible for these programs.  

Children who turn age 4 on or before September 1st will be prioritized for enrollment.  Children who turn age 4 September 2 through December 1st will be enrolled if space is available.  

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

CCRESA Logo


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:
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)
Other:
Is this more than stated on Parent/Guardian 1's 2017 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)
DHS Child Care Assistance
DHS Financial
DHS Food Assistance
Medicaid
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 and Great Start Readiness Program program providers.