Dear Preschool Parent(s),

What an exciting time for you and your child as you begin to explore preschool options. A quality preschool

experience makes a remarkable difference in Kindergarten preparation and success!

The Allegan Area Collaborative Preschool is made up of the following:

Great Start Readiness Program (GSRP) / Allegan Area

Education Service Agency (AAESA): A high quality free

preschool program for 4 year old children who reside in one of the

AAESA local districts where children, fun, and learning go hand in

hand. (Must meet GSRP state criteria)

Head Start / Allegan County Resource Development Committee (ACRDC): A high quality,

well-rounded free preschool for income eligible children in Allegan County who will be 3 or 4

years of age. There are additional programs for children birth – 3 and Head Start accepts children

of all abilities.

All programs offer:

Preparation of younger learners for success in school.

A variety of social and learning activities.

Exciting, informative parent and family activities.

We have included the Placement Form you requested. Please note that children must be 3 or 4 years of age by

October 1, 2014 to attend Head Start or GSRP. All of the information gathered is required by either state or federal

preschool guidelines. You must provide an income with proof and fill it out in its entirety or the placement

form will be returned. Please review the attached income guidelines for both Head Start and GSRP. Your

answers will help us determine your child’s proper placement in preschool. The form can be submitted by fax to

269.673.2361, mailed to Preschool 310 Thomas Street, Allegan, MI 49010, or emailed to sgonsior@alleganaesa.org.

If you have any questions, please call Susan Gonsior at 269.673.2161 x4139 or email sgonsior@alleganaesa.org.

Sincerely,

Allegan Area Collaborative Preschool Committee

* For additional childcare/preschool options in Allegan County, visit www.greatstartconnect.org.

Income Guidelines to Determine Eligibility for Head Start or GSRP

Persons in Family/Household

Head Start Eligibility Annual income below listed

amount

(100% FPL)

GSRP Eligibility Annual income below listed

amount

(250% FPL)

Potential GSRP Eligibility

(Above 251% FPL) Complete Placement Form for Preschool Collaborative

to determine eligibility. 1 $11,670 $29,175 $29,176 - $35,010

2 $15,730 $39,325 $39,326 - $47,190

3 $19,790 $49,475 $49,476 - $59,370

4 $23,850 $59,625 $59,626 - $71,550

5 $27,910 $69,775 $69,776 - $83,730

6 $31,970 $79,925 $79,926 – $95,910

7 $36,030 $90,075 $90,076 - $108,090

8 $40,090 $100,225 $100,226 - $120,270

For families/households

with more than eight

persons, add $4,020 for

each additional person.

For families/households

with more than eight

persons, add $10,050 for

each additional person.

GSRP Tuition Spots will

ONLY be offered if unable

to fill with those that

qualify for FREE first.

2014 - 2015 COLLABORATIVE PRESCHOOL PLACEMENT FORM

Complete and mail to: Preschool 310 Thomas Street, Allegan, MI 49010

Email sgonsior@alleganaesa.org OR Fax to 269.673.2361 *This form can be used for Early Head Start placement as well*

CHILD INFORMATION Child’s Name Child’s Date of Birth*:______/______/______

*Must be 3 or 4 years old by October 1, 2014.

Child’s Gender: M F Child’s Race:

Has your child attended Early Head Start? YES NO Has your child attended Head Start? YES NO

Have any of your children attended GSRP? YES NO (AAESA School Readiness Program)

Is this a Foster Child? YES NO Do you have legal custody or guardianship? YES NO

HOUSEHOLD Living Address: Street/Apartment

City / State / Zip: County

Mailing Address: (If Different)

City / State / Zip: County

Which School District do you live in? Circle One Allegan Fennville Hopkins Martin Plainwell Otsego Wayland

Email Address: Phone #1: Home / Cell / Work Phone #2: Home / Cell / Work

*Income Proof Required – Tax Return, W2’s, Pay Stub(s). Household Gross Income on 2013 Tax Return or last 12 months: ________________ # in Household: # of parents/guardians employed: Full time: Part time:

Do you receive any of the following:

Cash Assistance SSI Daycare Assistance Child Support Unemployment Workman’s Comp Veterans Benefits JET Program

Household – Please List All Members Last Name First Name Date of Birth Relationship to Child Employed?

Yes No

Last Name First Name Date of Birth Relationship to Child Employed? Yes No

Last Name First Name Date of Birth Relationship to Child Employed? Yes No

Last Name First Name Date of Birth Relationship to Child Employed? Yes No

Last Name First Name Date of Birth Relationship to Child Employed? Yes No

Please answer all as they apply to your child/family circumstances. Additional space is provided for other information you feel

may be helpful in determining eligibility. All responses are confidential and may prioritize placement.

Diagnosed Disability or Identified Developmental Delay Does your child have chronic ear infections? YES NO Allergies? YES NO If yes, please explain:

Can you understand your child’s speech/language? YES NO Can other people understand them? YES NO

Does your child have any chronic health issues? YES NO If yes, please explain:

Does your child have an IEP (Individualized Education Plan)? Current Issued by:

Does your child attend an ECSE (Early Childhood Special Education) classroom? YES NO

Previous Developmental delays: Cognitive Social Emotional Physical Speech

Behavior Concerns

Does your child have severe or challenging behavior issues? YES NO If yes, please explain:

Thank you for filling out this questionnaire. Use the space below to give any additional information that you would like to share: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ This is an application only and does not guarantee your child will be enrolled into a program. The Preschool Collaborative will review your application and determine which program your child is eligible to attend and is best suited to meet your child’s individual needs. If you wish to make a special request, indicate the program/location of your choice: _________________________ My signature verifies that the above information is correct and true to the best of my knowledge and I hereby release this information to be shared between the Allegan Area Collaborative Preschool Committee in the county in which I reside as well as to other early childhood programming in Allegan County for any children listed ages 0-5.

Parent/Guardian Signature: ___________________________________ Date: ____________________

State & Federally funded programs will not discriminate against anyone because of race, color, national origin, age or disability, except as prescribed by program guidelines.

English as a Second Language

Child’s Primary Language (if not English): Child’s Secondary Language:

Are parents able to speak English? YES NO If no, Primary Language: Language Preferred:

Abuse/Neglect of Child or Parent

Check this box if any of the following apply: Child or sibling has been abused or neglected; or parent has experienced domestic abuse; or a family member or someone in the home abuses alcohol, prescription medication, or non-prescription drugs.

Parent/Guardian Education Attainment Mother’s Education (Check highest level):

No High School Diploma – Highest Grade □ 8 □ 9 □ 10 □ 11 GED or High School Diploma Associate’s Degree Bachelor’s Degree Master’s Degree

Father’s Education (Check highest level): No High School Diploma – Highest Grade □ 8 □ 9 □ 10 □ 11 GED or High School Diploma Associate’s Degree Bachelor’s Degree Master’s Degree

Was either parent involved in special education while in school? YES NO Did either parent require math or reading assistance? YES NO

Environment

Are you living with family/friends/other due to economic hardship or loss of residence OR in a temporary housing situation? Yes No If yes, please explain:

Has your child experienced parental loss due to any of the following: Death Divorce Military Service Deployment Incarceration (Parent in jail) Other:

Do you have concerns that your child may have a developmental delay or disability? Yes No

Does anyone in your family (household) have a chronic health condition? Yes No If yes, please explain:

Is your child being raised by any of the following: Single Parent Grand Parent Foster Family Other

Does your child have any siblings that have either of the following: Chronic Health Issues Behavior Issues Please explain:

Was either parent 19 or younger when 1st child was born? Yes No 35 or older? Yes No Are you currently pregnant? Yes No If yes, please provide due date:

Office Use Only HS Waiver Needed (Income below 100%) Family ID#

Income: 0-50% 51-100% 101-150% 151-200% 201-250% 251-300% Income above 300% + 2 +1 +0 Contact Date ___________________ Contact Date ___________________ Contact Date ___________________ Office Signature: Date: