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Preschool Enrollment Form

Welcome to Eaton County Preschool

Preschool Picture

Are you looking for FREE high quality early childhood program within Eaton County for a child who is 3-4 years old and wondering if you qualify?

The Interest form on this website is the first step in the process to apply for state and federally funded preschool options. After completing the form, you will still need to complete program enrollment forms and provide documentation to verify eligibility. Completing this preschool interest form does not guarantee a program placement.

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 on 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 1 will be enrolled if space is available.

If you have questions please visit our “About Us” and “Frequently Asked Questions" page for additional information.

Preschool Application

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:

Program Preferences:

Preference 1:

Preference 2:

Preference 3:

Other Comments About Preferences

Parent/Guardian Information

Parent/Guardian 1:

First Name:

Last Name:

Parent/Guardian 2:

First Name:

Last Name:

Email Address:

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:

Child Lives With:

(check all that apply)

Number of people 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

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 2018 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 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

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?:

Childcare Information

Childcare Provider:

Name:

Childcare Address:

Street Address:

Street Address 2:

City:

State:

Zip Code:

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

©2019 Eaton Great Start Readiness Program · (517)541-8724 ·eatongsrp@eatonresa.org