2014-15 Kent County Preschool Intake Form
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22014-15 Kent County Preschool Intake
Please complete the below information in order to determine eligibility for free Preschool in Kent County. Return
this completed form to: Kent County Preschool Intake, Kent ISD, 2930 Knapp NE, Grand Rapids MI 49525. 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.)
Child Information:
List information regarding your child below:
Date: ____________________________
First Name: ____________________
Middle Name: ________________
Last Name: _______________________
Child’s legal name
Leave blank if none
Suffix: ________________________
Date of Birth: _________________
Gender:
Female
Male
(Eg. Jr., Sr., I, II, III, leave blank if none)
Race/Ethnicity: Is your child Hispanic/Latino?
Yes
No
Language spoken in the home: ____________________
Which of the following groups describes your child’s race? Please select at least one.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pafific Islander
White
How did you learn about Free Preschool? _______________________________________________________________
Head Start Categorically Eligible Factors
Please select all of the Head Start eligibility factors that apply to your child below (check all that apply). If one or more of
these factors are slected, your child is eligible for Head Start. In order to make the best decisions about your child’s
placement, please continue to complete the intake form.
Child and family is homeless
Child or family is receiving SSI
Child has an established IEP/IFSP
Child lives in foster care
GSRP Eligibility Factors
Please select all of the eligibility factors that apply to your child below (check all that apply).
Diagnosed disability or identified developmental delay
Severe or challenging behavior
Child is eligible for special education services or child’s develpmental
Child has been expelled from preschool or child care center.
progress is less than that expected for his/her chronological age, or
chronic health issues cause development or learning problems.
Primary home language other than English
Parent/guardian with low educational attainment
English is not spoken in the child’s home; English is not the child’s
Parent has not graduated from high school or is illiterate.
first language.
Abuse/neglect of child or parent
Environmental risk
Domestic, sexual, or physical abuse of child or parent; child
Parental loss due to death, divorce, incarceration, military
neglect issues. Child Protective Services report.
service, or absence; sibling issues; teen parent (not yet age
20 when first child born); family is homeless or without stable
housing; residence in a high-risk neighborhood (area of high
poverty, high crime, with limited access to critical community
services); or prenatal or postnatal exposure to toxic substance
known to cause learning or developmental delays.
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