Preschool and Infant/Toddler Application

Click here if you would like to learn more about the early childhood programs and services available in your area: https://www.umchs.org/page/locations

PARENT/GUARDIAN/CAREGIVER INFORMATION
I am the Parent/Guardian/Caregiver I am a community partner making a referrral Other

Who is filling out this form?
Parent/Guardian/Caregiver Name Parent/Guardian/Caregiver Name First Last
Parent/Guardian/Caregiver Date of Birth: Parent/Guardian/Caregiver Date of Birth: / MM / DD YYYY
Best Contact Phone Number Best Contact Phone Number - ### - ### ####
Email
Preferred Method of Contact

Preferred Method of Contact Text Phone Email
2nd Parent/Guardian/Caregiver Name 2nd Parent/Guardian/Caregiver Name First Last
Parent/Guardian/Caregiver Date of Birth: Parent/Guardian/Caregiver Date of Birth: / MM / DD YYYY
Best Contact Phone Number Best Contact Phone Number - ### - ### ####
Email
Preferred Method of Contact

Preferred Method of Contact Text Phone Email
FAMILY INFORMATION
Preferred Language:
Physical Address Physical Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Mailing Address (if different) Mailing Address (if different)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
APPLICANT INFORMATION
Which progam year are you applying for?
1. Name of Child 1. Name of Child First Last
Sex

Sex Male Female Other
Date of Birth Date of Birth / MM / DD YYYY
2. Name of Child 2. Name of Child First Last
Sex

Sex Male Female Other
Date of Birth Date of Birth / MM / DD YYYY
3. Name of Child 3. Name of Child First Last
Sex

Sex Male Female Other
Date of Birth Date of Birth / MM / DD YYYY
ADDITIONAL INFORMATION AND RESOURCES
Please provide any relevant information needed to coordinate services for your child and family.
Are you interested in any of the following for the participant or your family?

Are you interested in any of the following for the participant or your family? Child Care In-Home Visiting Food Housing Nutrition Health Disabilities Other
Please upload any supporting documentation such as TANF/SNAP Verification, Income, or Release of Information

For multiple documents, hold down the CTRL button to select more than one file.
I certify that I have read and understand this application. To the best of my knowledge, the information provided is true and complete. I understand that all information will be kept confidential within the agency.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Thank you for your interest in our early learning/preschool program and for submitting your application. We appreciate the opportunity to connect with your family. A member of our team will be in touch within the next few days to follow up.
Where did you hear about us?

Preschool and Infant/Toddler Application

Preschool and Infant/Toddler Application

PARENT/GUARDIAN/CAREGIVER INFORMATION

FAMILY INFORMATION

APPLICANT INFORMATION

ADDITIONAL INFORMATION AND RESOURCES

I certify that I have read and understand this application. To the best of my knowledge, the information provided is true and complete. I understand that all information will be kept confidential within the agency.

Thank you for your interest in our early learning/preschool program and for submitting your application. We appreciate the opportunity to connect with your family. A member of our team will be in touch within the next few days to follow up.