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2019-2020 Iosco Great Start Scholarship Application for 3-year-olds ONLY



This application is for 3 year olds in Iosco county who are seeking a scholarship to help cover the cost of preschool. Children must be 3 by September 1st. If you are applying for a scholarship there are few things to know before you do. Before completing the scholarship application please note that your preschool program must be participating in Great Start to Quality. If your program is not participating we are unable to consider your scholarship application. We do, however, encourage you to talk with your preschool program about joining Great Start to Quality. You can find more information about Great Start to Quality by visiting www.greatstarttoquality.org.
Untitled Title
Child's Name ( First, Middle, Last) *
Birthdate (If your child is a twin indicate birth order) *
MM
/
DD
/
YYYY
Sex *
Child's Race/Ethnicity: *
Parent(s)/Guardian(s) Name (First, Last) *
Mailing Address *
Physical Address: *
County *
Phone Number *
Email Address:
Have you already met or spoken with a staff member from either Head Start *
Required
Please list the name of the person you met or spoke with *
Please indicate which program your child will be attending. *
Child's School District *
Family Monthly Gross Income *
Income from most recent tax form *
Does your family receive any forms of state assistance? *
How did you find out about the COOR/Iosco Great Start Scholarship Program? *
Number of people in the family? *
Name and Ages of other children in the home? *
Is the child eligible for special education services or have an identified development delay and/or chronic health issues causing development or learning problems? If yes, please explain. *
Has the child's behavior prevented participation in a group setting, or has your child received a mental health referral? *
Required
Is the child's primary home language English? If not, please tell us the child's primary home language *
Have there been abuse or neglect of the child or parent? *
Required
Have there been parent loss by death, divorce, incarcerations, military services or absence? *
Have there been sibiling issues such as: chronic illness, behavior issues, disability, or dealth? *
Required
Was the child's parent(s) younger than 20 at the birth of their first child? *
Required
Did the chid have prenatal or postnatal exposure to toxic substances known to cause learning or developmental delays? *
Required
Tell us any additional information about your child (i.e. allergies)
I verify the information I have supplied is true. Failure to provide verification may result in our application being denied. *
Required
I hereby release this information to be shared amongst participating COOR Preschool Partnership Programs. *
Required
Would you like to receive information about the COOR/Iosco Great Start Collaborative? *
Required
If yes, how would you like to be contacted? *
Required
Are you interested in being a parent on the Great Start Collaborative or Great Start Parenting Leadership Group? *
Parents who participate in the Great Start Collaborative meetings receive a $20 stipend.
Required
In general, how do you like to receive information about local events and or information and programs in your area? *
Required
Would you like us to send you educational information and programs in your area by the ways you have chosen above? *
Required
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This form was created inside of C.O.O.R. Intermediate School District.