EARLY CHILDHOOD PROGRAMS OF NORTHWEST MICHIGAN CLIENT INTAKE

Program 1st Choice:
Program 2nd Choice: / School District / Age as of Sept1st, 20
years months / GSRP Eligible
Y N / Risk Factor / Refer to EHS/HS?

Y N

1. Child’s Legal Name: Last / First: / Date of Birth
2. Nickname: / 3. Parent, Guardian or Foster Name(s):
4. Phone H/M/W/C
(area code) / Street Address: / PO Box #:
City:
Zip:
5. Phone H/M/W/C
(area code)
6. Phone H/M/W/C
(area code)
7. Child’s Medicaid, Health Ins:
Child’s Medical Home/Physician’s
Name: / Dental Insurance #’s:
Child’s Dentist Name: / City / State
MICHIGAN
Zip Code / County
Ethnicity: Hispanic/Latino Y N Race: AI/AN Asian B/AA NH/OPI W / Gender: M F / Primary Language in home: English
Specify Other: / Program Year for Child: 1st 2nd 3rd
Transition EHS: Y N
8. Parental/Guardian Status (circle all that apply): One Parent Two Parents Foster Care Kinship Care Grandparent(s) Relative Other Teen
# of People: In Family [ ] # of Children: In Family[ ] Birth-3 years [ ] 4-5 years [ ]
9. Child Care
Y N / Early On/ISD Diagnosed Disability: Y N
(describe) / Medically Diagnosed Allergies:
Suspected Disability? Y N
Describe: / Special Accommodations Needed? Y N
Describe: /

Chronic/Serious Health and/or Dental Concerns?

Describe:
10. Was child professionally referred to program: Agency Name? / Why? How did you hear about us?
Y N
11. DHS Case # FAP (food assistance): Y N / E-mail:
12. Are you on:
WIC Y MIHP Y
HFA Y / Any specific family need/crisis or changes: Y N (circle all that apply) H M HiRisk HLTH FETAL HLTH RISK
(describe)
13. Pregnant Mother? Y N If yes, due date: / Veteran: Y Active Military: Y
First and last name of Parent/Guardian/Foster in family. / D.O.B / Gender / Educ. Level / Present Employment Status
A01 / M F /
F P U S R T
A02 /
M F / F P U S R T
First and last name of children in the family. / Related To? / How Related?
C01------PROGRAM APPLICANT------/ B12 A01 A02 / C F G R O
C02 / M F / B12 A01 A02 / C F G R O
C03 / M F / B12 A01 A02 /
C F G R O
C04 / M F / B12 A01 A02 / C F G R O
C05 / M F / B12 A01 A02 / C F G R O
14. INCOME (list by Family Member)
Family Member / Annual Income / Source
A. / $
B. / $
C. / $
Do you currently receive: Foster/Kinship Care: Y N
FIP: Y N Supplemental Security Income: Y N
Homeless: Y N /

TOTAL YEARLY INCOME

/ $ /

HS: E O EHS: E O

GSRP: E (at & under 250%) O (over 250%)

RETURNING 2nd Year Income Eligible

15. Certification: I certify that this information is true. If any part is false, my participation in this agency's program may be terminated and I may be subject to legal action. I also understand that the information in this application will be held in strict confidence within the agency and is accessible to me during business hours.

Parent/Guardian/Foster Signature: Date:

Income Verified By: [ ] W2’s [ ] Check Stubs [ ] Tax Return [ ] DHS [ ] Child Support [ ] Homeless [ ] Other

Birth Verified By: [ ] Certified Birth Certificate [ ] Hospital Birth Certificate [ ] Medicaid [ ] Other

Signature of verifying EHS/HS/GSRP staff member: Date:

06/16 DMT-White CFS/TEACHER/PROVIDER-Yellow FES/CC Coord-Pink P:\hsforms\u\recruitment\R-1a new