Preschool Enrollment Form

Welcome to Eaton County Preschool

Preschool Picture

 

EATON RESA Logo

 

 

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 your child is less than 3 years of age, please complete the application below. We will contact you with some family resources in Eaton County which may include information about home visiting, playgroup opportunities or Early Head Start. 

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

 


Preschool Application

School Year:
Please select the school year you are submitting this preschool application for:
2020-2021: Current school year, ending in June 2021.
2021-2022: Next school year, beginning in September 2021.
Child's Information
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:

Program Preferences:

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
 Text
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 2020 income tax return?

Yes   No

Is Parent/Guardian 1 enrolled in school and/or a job training program?

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.

Has an Individualized Education Program (IEP)
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.