2016-2017 Kent County Preschool Intake Form
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22016-2017 Kent County Preschool Intake
Please complete the below information in order to determine eligibility for free Preschool in Kent County.
If you have questions regarding this form, please call the Kent County Preschool Intake at (616) 447-2409.
(Please note that completion of this form does not guarantee a free Preschool placement.)
By completing this application you agree to the release of this information to be shared by Kent Intermediate School District, local school
district programs and with Community Based Organizations offering GSRP classrooms, for determining the appropriate pre-school
programs for your family
CHILD INFORMATION:
List information regarding your child below
Date: ____________
First Name: ____________________ Middle Name: _____________ Last Name: __________________
Suffix: _________
Female
Male Child Birthdate: ______________________
Street Address: __________________________________ Apt/Suite/PO Box: ______________________
City: _____________________________________
Zip: ________________
Resident District: ____________________________
Race: Is your child Hispanic/Latino?
Yes
No
Which of the following groups describes your child’s race? Please select at least one.
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Primary Language spoken at home: __________________ Secondary Language: __________________
FAMILY INFORMATION:
Complete the following information about your family. This
information is REQUIRED and will be critical for following your child’s application.
Mother First Name: _______________________ MI: ______ Last Name: ________________________
Daytime Phone Number: _________________________
Father First Name: _______________________ MI: ______ Last Name: _________________________
Daytime Phone Number: _________________________
Guardian First Name: ________________________ MI: ____ Last Name: _______________________
Relationship to child: _____________________________ Phone Number: ________________________
Emergency Contact Name: _________________________ Number: ____________________________
Relationship: _______________________________
Child Lives With: (Please check all that apply)
Mother
Father
Both Parents
Foster Care
Legal Guardian
Grandparent
Joint Custody – Physical
Joint Custody – Legal
Sibling in Head Start
HEAD START ELIGIBILTY FACTORS:
Child and family is homeless
Child or family is receiving SSI
Child has an established IEP/IFSP
Child lives in foster care
ANNUAL INCOME:
Household Income: ______________________
# of Household Members: ______________________
Family income to nearest dollar
Total # of people living in home
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