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Bussey Center for Early Childhood Education 24501 Fredrick St Southfield, MI 48033

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Child's Relationship (Required)

Custody

Lives with Family

Provides Financial Support

Teen Parent

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Middle Name

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Mobile Phone

Opt In for Text Messages

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race

Hispanic

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Are there other adults in the household?

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Number of Parents/Guardians (Required)

Relationship to Participant(s)

Primary Language at Home

Number in Household

Gross Annual Income

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services from WIC? (Required)

WIC ID (if applicable)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

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Middle Name

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Suffix

Nickname

Birthday (Required)

Gender (Required)

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English Proficiency (Required)

Primary Health Coverage (Required)

Doctor/Medical Home (Required)

Dentist/Dental Home (Required)

Does your child have a disability or do you have any concerns about your child's development?

Is there anything else you want to tell us about your child?

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Do you want to apply now for another child in your family?

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Are there other children in the family?

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Thank you for your interest in Bussey Center for Early Childhood Education. The first step of enrollment is to provide the documents listed below. Proof of Income Proof of Health Insurance Original Birth Certificate Physical (All results must be within a year). Height & Weight Blood Pressure Sickle Cell Anemia (done at birth) Hemoglobin or Hematocrit (numerical value) Blood Lead Level (numerical value) Hearing Test Vision Test Current Immunization Records Dental Exam Proof of child custody (if applicable) Proof of Residency (House Closing Papers or Mortgage Documents) (Apartment or House Rental Lease) AND (Two (2) Current Utility Bills (within 30 days) or Connection Notices)

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Child (Applicant)

Location Preferences

Additional Applicant

Siblings