EHS, HS, GSRP Application

Preschool Application Information
COLLABORATIVE PARTNERS

Joint Recruitment and Enrollment procedures are used to service families who reside in Chippewa, Luce, Mackinac counties. The procedures encompass Head Start, Great Start Readiness, child development centers and private preschools in the tri-county area. Those agencies include:

Free or Low-Cost Programs for Eligible Children
1. Chippewa-Luce-Mackinac Community Action Agency Head Start and Early Head Start
2. Eastern Upper Peninsula Intermediate School District Great Start Readiness Preschools (GSRP). Sites: DeTour, Engadine, Newberry, Pickford (Wee Wisdom), Rudyard, St. Ignace and Three Lakes; Chippewa-Luce-Mackinac Community Action Agency, Great Start Readiness Preschools (GSRP). Sites: Soo Township, Cedarville, and Brimley.
3. Inter-Tribal Council of Michigan - Bay Mills Head Start, Early Head Start, and Child Development Center
4. Sault Tribe of Chippewa Indians Head Start, Early Head Start, and Child Development Center
Tuition Based Programs
1. Immanuel Lutheran - Little Lambs Preschool
2. Superiort Start: The School Readiness Center & Preschool
3. Soo Co-op Preschool
4. St. Mary's Catholic Preschool
5. Tahqua Tots Learning Center
PURPOSE

The purpose of the Eastern Upper Peninsula Early Learning Collaborative joint recruitment and enrollment procedures is:
1. To offer a more streamlined process for families when enrolling their child in preschool.
2. To ensure that every eligible family who needs or wants preschool for their child is informed of their options.
3. To ensure that all programs reach capacity if there are children without a preschool.
4. To establish a universal "wait list" so families are enrolled in programs according to mandated priorities.
5. To establish an on-line intake form to allow families and providers easy access.
Program enrollment is determined by family preference, eligibility criteria, available slots, transportation needs, and other identified needs.
REQUIRED INFORMATION FOR ENROLLMENT

If applying to a GSRP or Head Start Program the following information will be required before the application can be processed.
- Certified Birth Certificate
- Income Verification: This information is confidential and will only be used for enrollment purposes. All the programs operated through GSRP, Head Starts and Early Head Starts have a variety of income guidelines. Income for the immediate 12 months prior to submission of the previous tax year must be verified. Income verification must include either W-2 forms, tax returns, statements from employers, the last 12 months of child support if receiving and/or verification of any other form of income. If your family receives Supplemental Security Income (SSI) or cash assistance (FIP) from the Department of Human Services, verification must be submitted with the application. If the child is a Foster Child verification in the form of court documents or a letter from the child's case worker must be submitted with the application.
- Health Information: Appraisals by physicians, completed health requirements, and updated immunizations are strongly encouraged to be completed prior to enrollment.
- Other Information: If you are in a situation where a parent or other person may not have access to your child due to custody or other issues, a current copy of the court order which indicates the restriction is required at the time of enrollment.
This intake form will be submitted directly to CLM Community Action Agency. The program will contact the family and assist them in completing the enrollment process for the individual program.
Eastern Upper Peninsula Early Learning Collaborative

RELEASE TO SHARE INFORMATION
I, First Name* Last Name* hereby authorize the sharing of information listed on the joint recruitment and enrollment in-take form regarding (child's name) First Name* Last Name* Date* to be shared with the programs and agencies who are members of the Eastern Upper Peninsula Early Learning Collaborative.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
ENROLLMENT APPLICATION

EUP EARLY LEARNING COLLABORATIVE
Child Information (Applicant)
School year applying for?*
Please check the one that applies

MaleFemale
Resident School District
Child's Name*

First NameLast Name
M.I.*
Date of Birth*

MonthDayYear
Date
Place of Birth (city, state)
Race/Ethnicity (optional) Check all that apply

BlackWhiteAsianNative AmericanHispanicPacific IslanderOther (see below)
If you selected other, please state the Race/Ethnicity.
Home Address*

Street

Street Address Line 2

CityState / Province

Zip Code
Please select the county you reside in.
Mailing Address (if different from above)

Street

Street Address Line 2

CityState / Province

Zip Code
Please select the county you reside in.
Primary Phone Number*
Please select the type of phone below
Please select the type of Phone Number*

HomeCellWorkMessage
Phone Number
Please select the type of phone below
Please select the type of Phone Number

HomeCellWorkMessage
Phone Number
Please select the type of phone below
Please select the type of Phone Number

HomeCellWorkMessage
May we text you at the phone numbers listed?

YesNo
Family Language:*

EnglishSpanishOther, see below
If you selected Other, please state the language
Do you require an interpreter?

YesNo
Session Preference:*

AMPMAll DayHome BaseAny
Note: We cannot guarantee the session you choose, but we will do our best.
Primary Parent/Guardian Information:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Relationship to Applicant*
Does this person live with the applicant?*

YesNo
Is this person employed Part/Full time?*

Part TimeFull TimeN/A
Is this person attending school/college?*

YesNo
Email Address
example@example.com
Secondary Parent/Guardian Information:

If applicable
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Relationship to Applicant
Does this person live with the applicant?

YesNo
Is this person employed Part/Full time?

Part TimeFull TimeN/A
Is this person attending school/college?

YesNo
Email Address
example@example.com
If you are not the biological or legal step-parent of the child, do you have court-appointed custody?

YesNo
If yes, please attach the proper legal documentation.
Please upload legal documentation for custody (if applicable)

You will not be able to upload documents after the application has been submitted.
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Program of Choice (please rank 1st, 2nd, and 3rd choice for programs of interest):

	1st	2nd	3rd
Bay Mills EHS
CLMCAA EHS
Sault Tribe EHS
Bay Mills Head Start
CLMCAA Head Start
Sault Tribe Head Start
Superior Start (Ages 2.5-6)
Little Lambs Early Childhood Center
Sault Coop Preschool
St. Mary's Catholic School
Tahqua Tots Learning Center
Bay Mills Child Development Center
Sault Tribe Child Development Center
Great Start Readiness Program (GSRP) (For children 4 on or before Sept. 1st)

Great Start Readiness Program (GSRP) Site Location Preferred?
For children who are 4 on or before Sept. 1st
Number of people in the family*
Number of parents in Household*
Count people in the household supported by parents of applying child
Family's TOTAL YEARLY income for the past 12 months or else income reported on last year's income taxes
Please include copies of income verification: Tax forms, W-2's, etc.
Please upload copies of income verification: Tax forms, W-2's, etc.

You will not be able to upload documents after submitting the application.
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Do you receive SSI (Supplemental Security Income)?*

YesNo
Do you receive SNAP (Supplemental Nutrition Assistance Program) benefits*

YesNo
Do you receive FIP/DHS Cash Assistance?*

YesNo
This application may be shared with all programs listed on the cover page?*

YesNo
If transportation is unavailable, are you willing to transport?*

YesNo
Where did you hear about our programs?

Previous involvement with programFriend or relative involved in programFrom other agency/schoolFrom Intermediate School DistrictSign at a centerBillboardFlyer/Brochure/Post Card in the mailLocal free paperNewspaperFlyer on bulletin boardRadioYard signOther, see below
If you selected Other, please list where you heard about our programs
*** Filling out this application does not mean your child is enrolled or is qualified for any program. The agencies involved will determine what program your child may be eligible for and will send your paperwork to the appropriate program.***
This section is intended to address the homeless needs by McKinney-Vento Act 42 U.S.C. 11435. The answers to this residency information help determine services the applicant may be eligible to receive.
1. Is your current address a temporary living arrangement?*

YesNo
2. If no, please skip the rest of this section.

If yes, please answer the questions below.
Is this temporary living arrangement due to loss of housing or economic hardship?

YesNo
Where is the child presently living? (Select all that apply)

In a motelIn a shelterMoving from place to placeWith more than one family in a house or apartmentIn a place not designed for ordinary sleeping accommodations, such as a car, park, or campsite
Early Childhood Risk Factors

Please complete if applying for Early Head Start, Head Start, or GSRP Programs.
Child has active IEP and is receiving special education services

YesNo
If yes, please list providing school/agency
Child has an IFSP and receives Early On Services

YesNo
Child has health issues that could result in developmental delay or learning difficulty

YesNo
If yes, please list the Specialist or Medical Provider name:
Physician has referred for special education services

YesNo
Child has received a low score on a developmental screening

YesNo
Child's behavior has repeatedly prevented him/her from participating in a group setting (for example: preschool, church, or day care)

YesNo
A mental health professional has referred child for services

YesNo
Your child is entering school not able to speak English and must learn the language

YesNo
English is your child's second language

YesNo
One or both parents did not graduate from high school

YesNo
One or both parents have difficulty with reading or cannot read

YesNo
Child has been abused/neglected or there has been domestic/spousal abuse of parent/sibling

YesNo
There has been abuse of alcohol, prescription or non-prescription drugs by family members or in the home

YesNo
Parent deployed in the military

YesNo
Parent incarcerated

YesNo
Parent suffers from chronic illness/disability (physical, emotion, mental)

YesNo
Frequent changes in custody of child

YesNo
Grandparent is raising child

YesNo
Single parent or parents have divorced or separated

YesNo
Child is in foster care

YesNo
Child's situation is negatively affected by issues related to a sibling (chronic illness, behavior issues, disabiity, death)

YesNo
Child experiences daily exposure to environmental pollutants (lead exposure, rodents, insect infestations)

YesNo
Neighborhood has a high crime rate, violence, injury, drug abuse, or death rates

YesNo
Home is unsafe or crowded

YesNo
Home has lack of utilities or no space for children's play

YesNo
Child born with Fetal Alcohol Syndrome

YesNo
Child prenatally exposed to drugs

YesNo
Child suffers from respiratory problems because of environment

YesNo
Age of parent at the birth of their first child
Your response is voluntary, and the information provided about your child is confidential.
I certify that the above information is true and accurate. I understand that should verification determine that any part of the application is false, it may hinder the application process. I also understand that the information contained will be held in confidence and used to determine eligibility and program planning.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint alleging discrimination, write USDA, Office of Adjunction, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
Please upload a copy of the Child's Birth Certificate and Shot Records

You will not be able to upload documents after submitting the application.
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Preschool Application Information