Family Intake Information
Are you seeking information about programs in Lapeer County? This form is designed to gather information from you about your family and connect you with available services.

Some of the Lapeer County programs offered are:

* Early Head Start (EHS) - EHS programs provide intensive comprehensive child development and family support services to low-income infants and toddlers (under age 3) and their families, and to pregnant women and their families.

* Early On/Build Up - for eligible children, birth to 5, who need supports and services because of a potential developmental delay or diagnosed disability that could impact their education.

* Head Start - is a federally funded preschool program for children from ages three to five who are from families with incomes below the poverty guidelines are eligible for Head Start.

* Great Start Readiness Program (GSRP) - is Michigan's state-funded preschool Program for four-year-old children with factors which may place them at risk of educational failure. (Children must be 4 years old by September 1st of the current year.)

Please fill out the form below and it will be sent to the appropriate program (if you have multiple children, you will need to complete a form for each child). All of the following personal questions will assist us in connecting you with the appropriate program(s), as most of these programs have age and income eligibility requirements.
What program(s) are you interested in?
If interested in preschool, what district would you be interested in attending (check all that apply)...
What is your child's name (as on Birth Certificate - First and Last) or put "expecting"? *
What is their date of birth or when are you expecting? *
MM
/
DD
/
YYYY
Gender *
Street Address *
City *
Parent/Guardian Full Name(s) *
Phone Number *
Secondary Phone Number
Email address
Preferred method of contact. *
Required
Is your child receiving a service such as Speech, Physical Therapy, or Occupational Therapy with an IFSP/IEP (Individualized Family Service Plan)/(Individualized Education Plan)? *
If yes, please describe.
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)? *
What is the approximate dollar amount of your current family income? (In the next question mark whether this is Weekly, Bi-Weekly, Monthly, or Yearly) *
Is this income monthly, yearly, weekly, or bi-weekly? *
Has your child been referred/involved in: (check all that apply) *
Required
How did you hear about the program(s) you're interested in?
Last question, where did you find this link to complete this form? (For Example: Facebook post from ____________, whose website, etc.) *
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. *
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) 245-3994. *Forms submitted in July will not be forwarded to programs until August.
Thank you for completing this form!
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