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Wayne State University Early Childhood Centers Pre-Screen Form
Parents/Guardians please complete this form if you are interested in putting your child on our waiting list.
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* Indicates required question
Child's Name
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Child's Gender
*
Female
Male
Prefer not to say
Children's Address
*
Your answer
Parent/Guardian's Name
*
Your answer
Parent/Guardian's Phone Number
*
Your answer
Alternate Phone Number
*
Your answer
Parent/Guardian's Email
*
Your answer
Check all that apply:
Wayne State University Employee
Wayne State University Student
Community Resident
Number of ALL household members (self, children, and other adults) for which you are financially responsible for
*
1
2
3
4
5
6
7
8
Required
Gross Income (before taxes)
*
Your answer
Frequency of pay
*
Weekly
Bi-Weekly
Monthly
Annually
Primary Language Spoken at Home
*
Your answer
Secondary Language Spoken at Home (if applicable)
Your answer
Special Needs/Special Circumstances (please explain)
Your answer
Wayne State University has two preschool programs on campus. Please indicate which center is your FIRST CHOICE for enrolling your child.
*
College of Education Early Childhood Center
Merrill Palmer Skillman Institute Early Childhood Center
Required
Please indicate which program option you are interested in (check all that apply):
*
GSRP (Great Start Readiness Program) Child must be 4 years old on or before September 1 and meet the income requirements
CCAMPIS Program (Parent(s) must be WSU undergrad or grad students (Open to children 3 & 4 years of age)
Tuition Program (Open to children 3 & 4 years of age)
Required
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