MCISD Early Childhood Program Inquiry Form

Inquiry/Pre-Application for Countywide Early Childhood Programs

MCISD Countywide Early Childhood Programs Inquiry/Pre-Application

Your child may be eligible for a variety of early childhood programs located in Monroe County. The following information will assist us in determining for which programs your child may be eligible for.

Today's Date: MM/DD/YYYY

STUDENT INFORMATION

Child's First Name:

Child's Middle Initial:

Child's Last Name:

Date of Birth: MM/DD/YYYY

Sex: (required) Male Female

Mailing Address:

City, State, Zip:

Ethnicity/Race (check all that apply): (required) American Indian or Alaskan Native Asian American Black or African American Native Hawaiian or Other Pacific Islander White Hispanic or Latino

Resident School District: (required) Airport Community School Bedford Public School Dundee Community School Ida Public School Jefferson School Mason Consolidated School Monroe Public School Summerfield School Whiteford Agricultural School

PARENT/GUARDIAN INFORMATION

1. Parent/Guardian's Name:

Relationship to Child:

Home Phone Number:

Cell Phone Number:

Email Address:

2. Parent/Guardian's Name:

Relationship to Child:

Home Phone Number:

Cell Phone Number:

Email Address:

Reason for Referral (examples: preschool program, home visitor, developmental concern, etc.):

Each of the preschool programs represented in this inquiry form has specific criteria for enrollment. Your child may not be eligible for the program you have inquired about, but may be eligible for different programs. We will for- ward this preliminary information. By signing this release you grant that records may be released or received by the following agencies: Monroe County Head Start Preschool/Early Head Start, Great Start Readiness Program, Early Childhood Special Education, Child Care Network, Early On, Other early childhood opportunities

Parent/Guardian Signature (print name in field):

Date: MM/DD/YYYY

The following information will allow the MCISD Early Childhood Team place your child in the best program to fit their needs.

Family Income (Information required to be considered for State or Federally funded preschool programs). Please include child support, if applicable, in this figure: Annual Income:

Number of individuals in the household (Information required to be considered for State or Federally funded preschool programs)

Please indicate ages of siblings:

Please check all that apply:

Receiving DHS - cash assistance (required) Yes No

Receiving SSI (social security income)? (required) Yes No

Diagnosed disability or identified developmental delay (required) Yes No

Family is homeless or without stable housing (required) Yes No

Child is in foster care (required) Yes No

Can you drive your child to and from school? Yes No

Thank you for completing the MCISD Early Childhood Inquiry form. This information will be reviewed by the MCISD Early Childhood Team. Once reviewed, you will be contacted to discuss the program that best fits the needs of your family. If you have further concerns, please feel free to contact the MCISD Early Childhood Team at 734.342.8780 or earlychildhood@monroeisd.us.

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