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Welcome to Van Buren Free Preschools

Welcome to Head Start and Great Start Readiness Program (GSRP) preschool enrollment!

Preschool Interest Form

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:

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

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)

Temporary Assistance for Needy Families (Family Independence Program)
Other:

Is this more than stated on Parent/Guardian 1's 2019 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.

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, Great Start Readiness Program, and Home Visiting Program providers.

This Van Buren Intermediate School District hereby agrees that it will comply with State and Federal Laws prohibiting discrimination and with all requirements imposed by or pursuant to regulations of the United States Department of Education. It is the policy of the Van Buren Intermediate School District that no discriminatory practices based on race, color, religion, national origin, sex, age, height, weight, marital status, disability, genetic information or any other status covered by federal, state, or local law be allowed during any program, activity, service, or in employment. Inquiries regarding the non-discrimination policies should be directed to Barbara Matthews, Director of Finance & Operations or Dave Manson, Director of Special Education, 490 S. Paw Paw Street, Lawrence, MI 49064, 269-674-8091.

These materials were developed under a grant awarded by the Michigan Department of Education.

Es la política del Distrito Escolar Intermedio de Van Buren que ninguna práctica discriminatoria sea permitida basada en laraza, color, religión, origen nacional, sexo, edad, estatura, estado civil, discapacidad, información genética o cualquier otra condición cubierta por la leyfederal, estatal o local durante cualquier programa, actividad, servicio o en el empleo. Las preguntas sobre las políticas de no discriminación deben ser dirigidas al Directora de Finanzas y Operaciones, Barbara Matthews o al Director de Educación Especial, Dave Manson, 490 S. Paw Paw Street, Lawrence, MI 49064, 269-674-8091.

Estos materiales se desarrollaron de acuerdo con una subvencion del Departamento de Educacion.

This site was developed by Clinton County RESA Office of Innovative Projects with funds from a grant awarded by the Michigan Department of Education.