Preschool Enrollment Form

Welcome to the St. Joseph County Quality Preschool Partnership

Preschool Picture

Are you looking for free high quality early childhood programs within St. Joseph County for a child who is birth to 4 years old and wondering if you qualify?

Please fill out the application form below to determine if your child is eligible to attend a FREE Great Start Readiness Program (GSRP), Head Start, or an Early Head Start program in St. Joseph County. For more information on available local programs and eligibility criteria, click on About Us. Any family wishing to apply for GSRP, Head Start or an Early Head Start program in St. Joseph County must complete this application form. If you have any questions about this form please call the Early Childhood Department at the St. Joseph County ISD at 269-467-5400.

Bienvenidos al Condado de St. Joseph

¿Está buscando programas de primera infancia de alta calidad dentro el Condado de St. Joseph para su niño/a de 0 a 4 años de edad y se pregunta si congrega los requisitos?  Por favor complete el formulario de solicitud a continuación para determinar si su niño/a es elegible para asistir GRATIS un Programa de Preparación de Preescolar de Great Start,  Head Start, o Early Head Start en el Condado de St. Joseph.  Para obtener más información sobre los programas disponibles y los criterios de elegibilidad local, seleccione Acerca de Nosotros (About Us).  Cualquiera familia que desea solicitar GSRP, Head Start, o Early Head Start en el Condado de St. Joseph, debe completar este formulario de solicitud.  Si usted tiene alguna pregunta sobre este formulario, por favor llame al Departamento de la Primeria Infancia en el St. Joseph County ISD al 269-467-5424.

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Preschool Application

Child's Name:

Date of Birth:
Gender: Male
(check all that apply)
American Indian or Alaska Native
Black or African American
Native Hawaiian or Other Pacific Islander
Hispanic of any race

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?
Marital Status:
Child Lives With:
(check all that apply)
Both Parents
Joint Custody-Physical
Joint Custody Legal
Foster Care
Legal Guardian
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)
Child Support
Supplemental Security Income (SSI)
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)
DHS Child Care Assistance
DHS Financial
DHS Food Assistance
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?:
 Community Organization
 Friend/Family Member
 Teacher/Education Professional
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.