Preschool Enrollment Form

Welcome to Lenawee County Preschools

Preschool Picture

Are you looking for free high quality preschool within Lenawee County for a child who is 3 to 5 years old and wondering if you qualify? Please fill out our interest form below or call 517-264-5324 to determine if your child is eligible to attend a FREE Great Start Readiness Program (GSRP) or FREE Head Start preschool program in Lenawee County. For more information on available local programs and eligibility criteria, click on About Us. Any family wishing to apply for GSRP or Head Start in Lenawee County must complete this interest form.

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.

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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:

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:

() -

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 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 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 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.