Please indicate interest in Early Head Start (Pregnancy to Age 3 home visit program) or Head Start (Ages 3-4) and Great Start Readiness Program (Age 4) preschool program. Children must be age 3/4 on or before December 1 of the school year to be eligible for preschool. Completion of this interest form does not guarantee your child will be served by a publicly funded preschool program. As part of the application process you will need to provide: • Proof of birth • Annual income/eligibility documentation Completion of this interest form or program application does not guarantee your child will be served by a publicly funded preschool program. IMPORTANT: If, after you enter your email address, you receive a message indicating that you have already applied you must contact Community Action Agency. Please contact Nadia Trumble at 517-257-9287 or email ntrumble@caajlh.org.
Parent/Guardian
Please note that some fields are required.
First Name (Required)
Last Name (Required)
Birthday (Required)
Email Address (Required)
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
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.
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
Doctoral Degree
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Address
Who is considered homeless? Under the McKinney Vento Act, the term "homeless children and youths" means individuals who lack a fixed, regular and adequate nighttime residence and includes children and youths: (1) who are sharing the housing of others due to loss of housing, economic hardship, or a similar reason; are living in motels, hotels, trailer parks or camping grounds due to the lack of alternative adequate accommodations; are living in emergency or transitional shelters; or are abandoned in hospitals; (2) who have a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings; (3) who are living in cars, parks, public spaces, abandoned buildings, substandard housing, bus or train stations, or similar settings; and (4) who are migratory children who live in one of the above circumstances. If you find yourself in one of these situations, please indicate below that you are experiencing homelessness.
Is your family experiencing homelessness?
Yes
No
Living Address (Required)
Address Line 2
City (Required)
State (Required)
ZIP (Required)
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to find a provider in your area.
Mailing Address same as Living Address
Mailing Address
Address Line 2
City
State
ZIP
Additional Parent/Guardian
Is there another parent/guardian in the family?
Yes
No
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Email Address
Confirm Email Address
It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.
Mobile Phone
Opt In for Text Messages
Yes
No
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.
Highest Grade Completed
Associate's Degree
Bachelor's Degree
College Degree/Training Cert.
College or Advance Training
Doctoral Degree
General Education Diploma
Grade 10
Grade 11
Grade 12
Grade 9 or less
High School Graduate
Master's Degree
Employment Status
Full-time & Training
Full-time (35 hours/week or more)
Part-time & Training
Part-time (Under 35 hours/week)
Retired or Disabled
Seasonally Employed
Training or School
Unemployed
Child's Relationship
Biological/Adopted/Step
Foster
Grandchild
Other
Custody
Yes
No
Lives with Family
Yes
No
Provides Financial Support
Yes
No
Teen Parent
Yes
No
Family Information
Relationship to Participant(s)
Foster parent(s) not including relatives
Grandparent(s)
Other
Parent(s) (e.g. biological, adoptive, stepparents)
Relative(s) other than grandparents
Primary Language at Home
American Sign Language
Asian
Chinese
English
Filipino
French
Indian
Italian
Japanese
Punjabi
Spanish
Tamil
Vietnamese
Yukrainian
Number in Family
Gross Annual Income
Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?
Yes
No
Is your family receiving Supplemental Security Income (SSI)?
Yes
No
Child (Applicant)
If your child has an IEP (Individualized Education Plan) or IFSP (Individualized Family Service Plan) please select "yes" for the question "Does your child have a disability?" In the note area, please provide information about your child's specific needs. If you are a pregnant mother applying for Early Head Start, please enter parents information for First Name, Last Name, and Date of Birth.
First Name (Required)
Middle Name
Last Name (Required)
Birthday (Required)
Gender
Female
Male
Does your child have a disability or do you have any concerns about your child's development?
Yes
No
Is there anything else you want to tell us about your child?
Location Preferences
Which program are you applying for? (Required)
2024-2025 School Year
2023-2024 School Year
Location Preference
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1st Location Preference
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2nd Location Preference
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3rd Location Preference
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- Your Address
- Available Locations
Click a location on the map to see more info
Click here
to find a provider in your area.
Additional Applicant
Do you want to apply now for another child in your family?
Add Another Applicant
Siblings
Are there other children in the family?
Add a Sibling
Thank you for your interest in Hillsdale County Early Childhood programming. By completing and submitting this form you are giving permission for us to contact you regarding your child's potential eligibility for the Early Head Start, Head Start and Great Start Readiness Program preschool. Community Action Agency and the Hillsdale County Intermediate School District will have access to the information you submit. You will receive a call from the Appointment Scheduler at Community Action Agency to schedule an application appointment for Head Start or Early Head Start. During this appointment you will be able to discuss your needs and select the location(s) you wish your child to be waitlisted for. You will also learn the differences between the Head Start program and Great Start Readiness Program. Head Start is a federally funded program and can offer additional supports that may be of help to your child and family. While speaking with the Family Engagement Specialist, you can decide if you would prefer not to attend Head Start (if you are income eligible). If you choose to enroll in the state funded Great Start Readiness Program, you agree to waive Head Start services by submitting this form. Those interested in applying for Great Start Readiness Program for four year olds will be contacted by HCISD. For questions, please call 517-689-1842. If you have any questions about this form or experience any problems while completing it, please contact Community Action Agency at 517-437-3346, press 3246 for assistance. You can also contact Nadia Trumble at 517-257-9287 or email ntrumble@caajlh.org. Parent Certification Statement: I certify that this information is true. If any part is false, my participation in this agency's programs may be terminated and I may be subject to legal action.
Required information is missing, see above.