Directions: If you would like to apply for preschool benefits from Head Start and GSRP (Great Start Readiness Program) in our Calhoun County, MI, area, please complete the form below. Your child is worthit!
After completing this form, please mail itto:
Calhoun Area CareerCenter
Attention: GSRP - ChristieCipcic
475 East Roosevelt Ave. Battle Creek, MI49017
Phone:(269) 660-1606 ext.6141
Website:
ChildInformation(Applicant):MaleFemale
Legal Name (First and Lastname):
DateofBirth://Place of Birth (City,State):
Race/Ethnicity (Check allthatapply):BlackWhiteAsianNativeAmericanPacificIslanderHispanic Other:
FosterChild?YesNoFoster Child for less than6months?YesNo
HomeAddress: City: State ZIP: County: School District youresidein: Are you able toprovidetransportation? Yes No Is your currentaddresstemporary? Yes No
If temporary, where is the childcurrentlyliving?InamotelIna shelterMoving from placetoplaceIn a place not designed for ordinary sleeping accommodations such as a car, park orcampsite
More than one family living in a houseorapartmentOther(explain): Phonenumber:( ) Thisnumberis: HomeNumber CellNumber WorkNumberPhonenumber:( ) Thisnumberis: HomeNumber CellNumber WorkNumberPhonenumber:( ) Thisnumberis: HomeNumber CellNumber WorkNumberE-mailaddress: Alternative contact person (adult) -- This person will be contacted in the event that the parent(s) areunreachable:
Name:Phonenumber:()
Familylanguage:EnglishSpanishOther:
Do you requireaninterpreter?YesNo
Parent / GuardianInformation:
Name(s)DateofbirthRelationship toapplicant(Child)Living with thechild?
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YesNo
YesNo
List all other adults or children in thefamily:
Name(s)DateofbirthRelationship to applicant(Child)
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//Does the child you are applying for receive SpecialEducationservices? Yes No Release of Information &Consent:
This is the Community Action Education and Children’s Services Release of Informationregarding
(Child’sname): I, , as parent/guardian, hereby give mypermissionfor Community Action ECS to contact the Calhoun lSD for information regarding my child. I consent to have the Calhoun County ISD share my child’s preschool application with Community Action, Child Care Resources, Great Start Collaborative, local school district and other lSD Birth to 5programs.
Signature of Parent/Guardian:Date://
Income Information: (Please attach proof of income such as)
Does anyone in the family receive Supplemental SecurityIncome(SSI)?YesNo Do you receive DHS Cash Assistance, FIP, DHS Dollars orTANF Money? Yes No
What is the total gross income for your family peryear:$(Put “0” if no income received in past12months.) Number of people in your family who are supported by the parent(s)/ guardians of thechild:
AgreementStatement:
I understand that the completion of this application does not guarantee that my child is qualified or enrolled in any program. I certify that all the information submitted is true and accurate. I understand that if any part this application is false, it may hinder the application process. I also understand that the information submitted will be heldinconfidenceand used to determine eligibility for preschoolonly.
Signature of Parent/Guardian:Date://
Where did you hear about our programs? (Check all thatapply)
NewspaperLocalfreepaperSignatcenterPrevious involvementwithprogramOther agencyorschoolFlyer Doorhanger left atyourhome Poster Website E-mail Word ofMouth Facebook orSocialMediaRadio Television InternetSearch Friend or relative involvedinprogram From Intermediate SchoolDistrict
Other source of information about ourprograms:
Need Help? Call our Help Line at (269) 660-1606 ext. 6141 from 7:30 a.m. to 3:30 p.m., Monday - Friday.
EarlyChildhoodRiskFactors
Please answer each question in the right hand column with a yes orno.
Parentsdonotfill outsectionsunder "FOROFFICEUSEONLY11
RiskFactor
Childisdiagnosedwith a disability or
has an identified developmental delay
Severe or challenging behavior
Primary home languageotherthanEnglish
Parent/s withlow educational attainment
Abuse/neglect of child orparent
Definition
Child is eligible for special education services or child's developmental progress is less then that expected for his/her age or has chronic health issues causing development or learningproblems.
Child has beenexpelled from a preschool or child carecenter
English isnot spokenin child'shome;
English is not the child's firstlanguage.
Parent has not graduated from high schoolorisstruggling withilliteracy.
Domestic,sexual,or physicalabuseofchild orparent;childneglectissues.
PleasecheckYesorNooneachquestion.
DYesDNo-ChildhasactiveIEPandisreceivingspecial educationservices
DYesDNo-ChildhasanIFSPandreceivedEarlyOnServices
DYesDNo-Childhashealthissuesthatcouldresultina developmentaldelayorlearningdifficulty.
DYesDNo-Physicianhasreferredforspecialeducationservices
DYesDNo-Childhasreceivedalowscoreonadevelopmental screening
DYesDNo-Child'sbehaviorhasrepeatedlypreventedhim/her from participating in a group setting (forexample:
preschool,church,ordaycare)
DYesDNo-Amentalhealthprofessionalhasreferredchildfor services.
DYesDNo-Yourchildisenteringschoolnotabletospeak Englishandmustlearnthelanguage.
DYesDNo-Englishisyourchild'ssecondlanguage.
DYesDNo-Oneorbothparentsdidnotgraduatefromhigh school
DYesDNo-Oneorbothparentshavedifficultywithreadingor
cannotread.
DYes DNo - Child has been abused or neglected or there has beendomesticorspousalabuseofparentorsibling.
DYesDNo-Therehasbeenabuseofalcohol,prescriptionor non-prescriptiondrugsbyfamilymembersorin
thehome.
EnvironmentalRisksParentallossdueto
death, divorce, incarceration,militaryservice,orabsence.
DYesDNo-Parentdeployedinthemilitary
DYesDNo-Parentincarcerated
DYesDNo-Parentsuffersfromchronicillness(physical,
emotional,mental)
DYesDNo-Frequentchangesincustodyofchild.
DYes DNo -Grandparent raising grandchild
DYesDNo-Singleparentorparentshavedivorcedorseparated
DYesDNo-Childisinfostercare.
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Directions: After completing this form, please mail itto:
Calhoun Area CareerCenter
Attention: GSRP - ChristieCipcic
475 East Roosevelt Ave. Battle Creek, MI49017
Foradditionalinformationaboutthisapplicationandthepreschoolenrollmentprocess,pleasecall(269)660-1606,ext.6141