GSRP/Head Start Intake Information
This form is designed to gather information from you about your family. We will use this information to see if you qualify for GSRP or Head Start and get your information to the program that best suits you.

In order to qualify for GSRP, your child must be 4 years old by September 1st of the current year.

What is your child's name (as on Birth Certificate - First, Middle, and Last)? *
Your answer
What is their date of birth? *
MM
/
DD
/
YYYY
Gender *
Street Address *
Your answer
City *
Your answer
Parent/Guardian Name(s) *
Your answer
Phone Number *
Your answer
Secondary Phone Number
Your answer
Email address
Your answer
Preferred method of contact. *
I would like to see if my child is eligible to attend preschool in (check all that apply)... *
Required
Is your child receiving a service such as Speech, Physical Therapy, or Occupational Therapy with an IEP? *
If yes, please describe.
Your answer
Where are you and your child currently living? *
Who does the child live with? (check all that apply) *
Required
How many people are in your family (adults and children)? *
Your answer
What is your family income? *
Your answer
Is this income monthly, yearly, weekly, or bi-weekly? *
Is your family receiving assistance? *
Required
Do you have a family member that is active military? *
If yes, relationship to child.
Your answer
Has your child been referred/involved in: (check all that apply) *
Required
How did you hear about GSRP?
Your answer
I authorize my name and family information to be shared via email with collaborating programs in an effort to avoid duplication of services. Please type your full name and today's date on the line below. *
Your answer
Lapeer County Intermediate School District will forward your information to the program(s) you have selected. If you do not hear from the program(s) within 2 weeks*, please call (810) 245-3963. *Forms submitted in July will not be forwarded to programs until August.
Thank you for completing this form!
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