Diagnosed Disability or Identified
Developmental Delay
IEP
Early On
Screening Tool ______
Parent Report ______
Doctor Report ______
GSRP #2 / Parent/Guardian(s) with low
educational attainment
Father:
Mother:
GSRP #5
Abuse/Neglect of child or
parent
Child
Parent
Sibling
Family Member
Person in the Home
Drugs
Alcohol
Physical
GSRP #6 / Environmental Risk
Loss of parent:
Reason:
Sibling Issues:
(chronic illness, behavioral issues, disability, death)
Reason:
Teen Parent:
(not yet 20 at birth of 1st child)
Homeless or without stable housing
Residence in high riskneighborhood
Prenatal or Postnatal exposure
to toxic substances
GSRP #7 / Income
Low income at or below 250% of federal poverty level (FPL)
GSRP #1
251% - 300% federal poverty level (FPL)
301% - 350% federal poverty level (FPL)
351% and above (FPL)
Severe or Challenging Behavior
Expelled from:
Preschool ______
Childcare ______
Mental Health Referral ______
GSRP #3
Primary Home Language OTHER
than English:
Language Spoken: ______
GSRP #4
School Readiness Application Release
Our goal with this release is to assist you in finding the school readiness program that best meets the needs of your family. Factors that mayaffect your child’s eligibility for these programs include but are not limited to a child’s age, child and family needs, family income, and in some instance, location and/or transportation options. Coordinating the application process increases the likelihood of your child’s placement. Your signature below will allow non–profit licensed programs, who are involved in this coordination, to effectively consider all aspects ofyour child’s eligibility.
RELEASE OF APPLICATION INFORMATION
I, parent/guardian of said child, have read the above statement and understand the reason for this release of information. Further, I authorizethe sharing of my child’s application information with the LocalSchool District, the IntermediateSchool District, Head Start or any non-profitlicensed school readiness program. This authorization shall remain in effect one year from signature date.
Child’s Name: ______Birth Date: ______
Parent/Guardian Signature: ______Date Signed: ______
Four Year-Old Head Start Eligibility Waiver
Although my child is Head Start eligible, my preference is to apply for the GSRP State School Readiness Program for four year-olds.
Reason for preference: ______
______
______
______
Parent/Guardian Signature: ______Date Signed: ______
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