Wayne State University Early Childhood Centers Pre-Screen Form

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Parents/Guardians please complete this form if you are interested in putting your child on our waiting list.

Child's Name *

Child's Date of Birth *

YYYY

Child's Gender *

Female

Male

Prefer not to say

Children's Address *

Parent/Guardian's Name *

Parent/Guardian's Phone Number *

Alternate Phone Number *

Parent/Guardian's Email *

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 *

Required

Annual Income (before taxes) *

Primary Language Spoken at Home *

Secondary Language Spoken at Home (if applicable)

Special Needs/Special Circumstances (please explain)

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 Dec. 1. No income requirements.

Tuition Program (Open to children 3 & 4 years of age)

Required

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