MCISD Early Childhood Program Inquiry Form

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 Asian African American Native Hawaiian or Other Pacific Islander White

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:

Occupation:

Number of Hours worked each week:

2. Parent/Guardian's Name:

Relationship to Child:

Home Phone Number:

Cell Phone Number:

Email Address:

Occupation:

Number of hours worked each week:

Reason for Referral:

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: (required) $0 - $20,000 $20,000 - $40,000 $40, 000 -$60,000 $60,000 - $100,000 over $100,000

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

Was the child born prematurely?

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

Your child has a severe or challenging behavior

Primary home language other than English

Parent/guardian with less than high school education

Abuse/neglect of child

Victim of domestic violence

Parental loss due to death, divorce, incarceration, military service or absence

Teen parent

Age at the time (mother and father):

Residence in a high-risk neighborhood (area of poverty, high crime, with limited access to critical community services)

Prenatal or postnatal exposure to toxic substances known to cause learning or developmental delays (such as lead, second-hand smoke, marijuana or other drugs, etc.)

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

Child’s situation is negatively effected by issues related to a sibling (e.g. chronic illness, behavior issues, disability, death)

Where did you hear about our services (check one)? Relative/Friend Round-Up Event BabyNet Packet Celebrate Children Festival Great Start Event Newspaper Phone Call Other

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 734.242.5799, ext. 1610 or earlychildhood@monroeisd.us.