Imlay City GSRP & Head Start Application
Please fill this form out completely.  An Imlay City GSRP staff member will contact you to set up a follow-up appointment to go over income and eligibility factors.  This application is not considered complete until all documentation is turned in and an in-person interview is completed.

Please note that GSRP is not a first come, first serve program.  All applications and documentation is collected and eligibility is based on income and greatest educational need according to eligibility factors. Because this is a state-funded preschool program, we cannot enroll students into GSRP until the Governor releases funds. This typically happens in August.  

PLEASE NOTE: There is NOT AN OPTION TO SAVE this application and go back into it later.  You will want to make sure you have the following information available when you fill out the application:  
*Child's doctor's name and phone number
*Name and phone number for at least one emergency contact


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Email *
Program Requested *
Child's Full Name *
First, Middle, Last
Date of Birth *
MM
/
DD
/
YYYY
Will your child be 4 years old on September 1, 2020? *
Gender *
Child's Home Address *
Number, Road, City, State, Zip
County of Residence *
Home School District *
ISD
Clear selection
Primary Phone *
Secondary Phone *
How many people are in your family? *
Adults & Children
What was your 2019 total family income? *
*As reported on taxes.  (Proof of income will be verified.)
Birth Father's Name *
First & Last
Birth Mother's Name *
First & Last
Birth Parents are *
Child lives with *
 Please check all that apply.
Required
Where does child stay at night? *
Race *
Hispanic or Latino *
Primary Language *
Does your family migrate? *
If yes, approximate dates of migration?
Father/Legal Guardian
Father/Legal Guardian's Name *
If not applicable, please write N/A
Father/Legal Guardian's Date of Birth *
If not applicable, please write N/A
MM
/
DD
/
YYYY
Father/Legal Guardian's Relation to Child *
Father/Legal Guardian's Education Level *
Check highest achieved.
Father/Legal Guardian is Employed *
Father/Legal Guardian is in School/Job Training *
Mother/Legal Guardian
Mother/Legal Guardian's Name *
If not applicable, please write N/A
Mother/Legal Guardian's Date of Birth *
If not applicable, please write N/A
Mother/Legal Guardian's Relation to Child *
Mother/Legal Guardian's Education Level *
Check highest achieved.
Mother/Legal Guardian is Employed *
Mother/Legal Guardian is in School/Job Training *
Is mother currently pregnant? *
List first and last name and birth date of others in household supported by income of parent/guardian(s)
Dependent #1 Name
First & Last
Dependent #1 Date of Birth
MM
/
DD
/
YYYY
Dependent #2 Name
First & Last
Dependent #2 Date of Birth
MM
/
DD
/
YYYY
Dependent #3 Name
First & Last
Dependent #3 Date of Birth
MM
/
DD
/
YYYY
Dependent #4 Name
First & Last
Dependent #4 Date of Birth
MM
/
DD
/
YYYY
Dependent #5 Name
First & Last
Dependent #5 Date of Birth
MM
/
DD
/
YYYY
Dependent #6 Name
First & Last
Dependent #6 Date of Birth
MM
/
DD
/
YYYY
Alternate Contact Name *
Alternate Contact Phone *
Active US Military *
US Military Veteran *
Referred by a Child Welfare Agency *
SNAP *
WIC *
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