Wayne County GSRP Pre-Screen Form
Child's Date of Birth *
MM
/
DD
/
YYYY
Sex of Child *
Child's Name *
Your answer
Child's Address *
Your answer
Phone Number *
Your answer
Alternate Phone Number
Your answer
e-Mail *
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Name
Your answer
Number of ALL (self, children, and other adults) household members for which you are financially responsible: *
Your answer
Gross Income (How Much Money Did You Make in 2019) *
Your answer
I Will Prove My Income By: *
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