Great Start Early Childhood Scholarship Intake Form
I am interested in seeking tuition support for my child to attend local child care or preschool during the time period of
September, 2011 through September, 2012. Tuition for either up to a maximum of $5,400 will be billed by the
placement to the Great Start Early Child Care Fund. Complete fulfillment of child care/preschool requirements and
policies is required for receipt of this scholarship, including parental involvement and adherence to attendance and
withdrawal policies connected with the child care/preschool placement location. I am responsible for completing all
enrollment paperwork required by the placement.
Child’s Name: __________________________________________Birth date:___________
Child Race/Ethnicity: ___ African American
___ Asian
___ Caucasian
___ Hispanic or Latino
___ Multi Racial
Sex: M
F
___ Native American
___ Other
Parent/Guardian’s Name: ____________________________________Phone number: ____________
Address: _______________________________________________
(Street)
(City)
(Zip)
School district: ________________________
County: (please circle)
Crawford
Iosco
Ogemaw
Oscoda
Roscommon
Where did you find out about the Great Start Childhood Scholarship? _______________________
Family Monthly Gross Income: _______________
Proof of income must be attached to be considered for eligibility. (pay stub, TANF form, tax form)
# of People in our Family: ____
The following apply to our family. Place a check next to all that apply:
_____ Our family is not eligible for State Child Care Reimbursement.
_____ Our family’s gross income meets the guidelines listed below. Please circle the amount in the table below that
most closely represents your family’s annual income. This will help us determine if you are eligible for a child care
scholarship or other assistance (based on assessment of need.)
Please check any/all that apply: One or more of the parents that are the full-time caretaker of this child are:
currently employed
actively seeking employment
currently attending school
to improve employment opportunities
State and Federally funded programs do not discriminate against any family because of race, color, national origin, sex, age or
handicap.
Great Start Early Childhood Scholarship Intake Form
200% OF POVERTY INCOME GUIDELINES
EFFECTIVE JULY 1, 2009 PEOPLE IN
THE HOUSEHOLD
1
2
3
4
5
6
7
8
200%
$21,660
$29,140
$36,620
$44,100
$51,580
$59,060
$66,540
$74,020
$7,480
Add this amount for each additional person
in the household with more than 8 people
Names/Ages of other children in the household:
RISK FACTOR SCREENING (for “YES” responses, circle the item in the question that applies)
1. Is the child eligible for special education services or have an identified developmental
delay and/or chronic health issues causing development or learning problems?
2. Has the child’s behavior prevented participation in a group setting, or has your child received a
mental health referral?
3. Is the child’s primary home language other than English?
4. Has the child’s parent not graduated from high school or had low educational attainment?
5. Has there been abuse or neglect of the child or parent?
6. Has there been parent loss by death, divorce, incarceration, military service or absence?
7. Sibling issues – chronic illness, behavior issues, disability, or death
8. Was the child’s parent/s younger than 20 at the birth of their first child?
9. Is the child’s family homeless or without a stable residence?
10. Does the child reside in a high-risk neighborhood? (high poverty, crime, limited access to
community services)
11. Did the child have prenatal or postnatal exposure to toxic substances known to cause learning or
developmental delays?
Tell us any additional information about your child to assist with referral. (allergies, etc.)
YES
State and Federally funded programs do not discriminate against any family because of race, color, national origin, sex, age or
handicap.
NO
Great Start Early Childhood Scholarship Intake Form
 I verify the information I have supplied is true.
 I understand that a voluntary declaration of income and number of persons in my family is necessary to make sure funds
are directed to families least able to secure child care from other sources. I understand that I am required to verify
my/our family’s income and disclose any other source from which I receive assistance for child care. Failure to provide
correct verification may result in our application being denied.
 I understand that any amount of child care scholarship received will go directly to the child care provider. The provider
will be responsible for submitting a bi-weekly statement and will track my child’s attendance to remain eligible for the
tuition assistance. It is expected that my/our child’s attendance will be at least 90%. If attendance does not meet 90%
and my child’s absences are unexcused (examples of excused absences include child illness, family crisis,) then the
child care provider will talk with me. Ongoing attendance problems may result in the loss of child care scholarship
assistance.
 I understand that my child will participate in assessment and evaluation by the child care provider and that I will be
expected to meet with the provider to discuss my child’s progress.
 I understand that involvement in my local Great Start Collaborative and/or Parent Coalition is strongly encouraged.
I hereby release this information to be share among participating Great Start Early Childhood Scholarship Programs.
_____________________________________________
Parent/Guardian Signature
_______________________
Date
Please indicate with #1 and #2 your First and Second choices of child care program which you would like your child to
attend:
_____
Local Head Start
_____ Great Start Collaborative Early Childhood Scholarship Program
_____ Private Provider
Name of provider:
Address of provider:
Contact (phone/email) of provider:
State and Federally funded programs do not discriminate against any family because of race, color, national origin, sex, age or
handicap.
Great Start Early Childhood Scholarship Intake Form
DO NOT WRITE BELOW THIS LINE. FOR STAFF USE ONLY
Referring Agency: ______________________________________________________________________
Name
Telephone number
Head Start review: Name: ___________________________________ Date:_________________
Action Taken: _________________________________________________________________________
Head Start waives this placement (E.H.S. Staff signature) ________________________________________
Program Assignment: ______________________________________ Date: _______________________
COMMENTS/NOTES:
PLEASE RETURN/SEND FORM TO:
Cindy DeLadurantaye
Scholarship Coordinator
COOR-Iosco Great Start Collaborative
P.O. Box 834
Grayling, MI 49738
Phone: (989) 344-9335
State and Federally funded programs do not discriminate against any family because of race, color, national origin, sex, age or
handicap.