Pentwater Preschool Application & Referral Form
It’s that time of year to register your child for Preschool!  If you have a child who turns 4 years old on or before December 1st, he/she may be eligible for our Great Start Readiness Program!

Please take a few minutes to complete the following form and we will be in contact with you shortly.  

Thank you for your interest in preschool for the 2024-25 school year!

Thank you,
Pentwater Preschool
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Email *
Child's First and Last Name *
Child's Birth Date *
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Gender *
Did this child attend any of the following: *
Required
Race *
Required
Ethnicity *
Primary Language *
Required
Special Needs *
Required
If your child has an IEP, what is it for:
Was child referred to the program? *
If yes, by whom and why?
Primary Health Coverage *
Doctor/Medical Home Name *
Dentist/Dental Home Name *
First and Last Name of Adult 1 *
Birth date of Adult 1 *
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Gender of Adult 1
Clear selection
Primary Phone Number of Adult 1 *
Secondary Phone Number or Cell Number of Adult 1 *
How are you Related: *
Required
Education *
Highest Grade Completed
Employment *
Does this individual live with family? *
Does this individual provide financial support for the family? *
Teen Parent: at birth of first child *
First and Last Name of Adult 2
Birth date of Adult 2
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DD
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Gender of Adult 2
Clear selection
Primary Phone Number of Adult 2
Secondary Phone Number or Cell Number of Adult 2
How are you Related:
Education
Clear selection
Highest Grade Completed
Employment
Clear selection
Does this individual live with family?
Clear selection
Does this individual provide financial support for the family?
Clear selection
Teen Parent: at birth of first child
Clear selection
Number in Family *
Required
List other adults in the home, relationship, and birth date.  (If none, please write NA) *
List other children in the family and their birth date. (If none, please write NA) *
Living Address *
City *
Zip *
County *
Residential Address *
City *
Zip *
County *
Is your mailing address the same as your living address? *
Active U.S. Military? *
Does your family receive food stamps? *
Does your family receive WIC? *
Last WIC visit?
MM
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Annual Income (Last 12 months) *
This information will be kept strictly confidential, and is used un determining eligibility. 

- Pentwater Preschool may ask for proof of your income at any time during the year.

- If your income changes by more than $500 per month, please notify the preschool.

- Upon reviewing the attachments and signing this agreement, the parent, legal guardian, or responsible adult and Pentwater Preschool staff agree to abide by the provisions above and the policies and provisions in the Parent Handbook.
I attest that I have submitted complete and accurate eligibility information including my income and living situation.
Parent/Guardian Signature *Please type your name below *
Email  *
Date completing the application *
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Thank you!
A member of our team will be in contact with you shortly.
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