Which school year are you applying for?: 2012-20132013-2014

How did you hear about WMA-ES?: WMAES WebsiteGR KidsKidsvilleGR FamilyFlierHome/Garden ShowParty for the PlanetPark PartyDriving ByGrouponMichigan Fun Pass

Last Name:

First Name:

Middle Name:

Name you want your child called at school:

Child's Current Age:

Date of Birth:

Gender: MaleFemale

Birthplace:

Home Phone:

Ethnicity: American IndianAsianAfrican AmericanHispanicCaucasian

Name:

Age:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Employer:

Work Phone:

Education Level: Less than 12th GradeHS GraduateTechnical TrainingCollege

Name:

Age:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Employer:

Work Phone:

Education Level: Less than 12th GradeHS GraduateTechnical TrainingCollege

Marital Status: SingleMarriedRemarriedDivorcedSeparatedLiving TogetherWidowed

Who has legal custody of child? (Name(s) and Relationship):

Name:

Address:

Phone:

Monthy:

Annual:

Low Birth Weight

Child immature

Nutritionally deficient

IEP (Individualized Education Plan)

Child has diagnosed disability

Child has long term or chronic illness

Referral by Doctor, ISD, or parent for screening

Speech difficulties, difficult to understand, difficulty expressing needs, does not speak in whole sentences

Comments:

Child is destructive or violent

Child in counseling or therapy or referred

Child has been asked to leave a Preschool or Child Care

Primary language spoken:

Additional Spoken Languages:

Cannot read

Have dropped out of school

Struggled in school

Comments:

Someone in our home was a victim of physical, sexual or emotional abuse or neglect

There is a history of substance abuse in our family (alcohol, drugs, prescription drugs, etc)

Someone in our home has violent, destructive temperament

Comments:

I am a single parent

Someone in our home is/was in jail or prison

My child has experienced the loss of a parent or sibling by death or loss of parent by divorce, military service, out of town employment, etc

My child has a chronically ill parent or sibling (behavior issues, physical, mental or emotional illness)

Teenage parent at birth of any of the children in family

My child is/has been in Foster care

Number of siblings my child has

Brothers:

Sisters:

We have moved in the last 2 years

Times moved:

We are living with:

Family

Friends

Shelter

Other

Our home is or may be in foreclosure

Unemployed parent(s)

Comments:

My child’s general health is: ExcellentGoodFairFrequently Ill

List any medication your child is currently taking:

People in home:

Total number of people living in the preschooler’s home:

Please list their names, age and relation to the child:

Family not in home:

Family Members (parents, siblings, step-siblings, etc) living outside of family home:

Please list family members names, age and relation to the child:

Did the child’s birth mother receive regular medical care during pregnancy?: YesNo

Biological child?: YesNo

Adopted?: NoYes

Were there any Problems at birth (mother or child)? Please describe:

Please describe any substance use (alcohol, drugs, tobacco) during pregnancy by mother or father:

Therapy (speech, PT, OT)

WIC

Early On Services

Aggression Management

Food Stamps

Early Head Start (ages 0-3)

Counseling

SSI

Readiness Groups at ISD

Alcohol/Drug Services

Child Protective Services

Wrap Around Service

Parenting Classes

Special Education Services/ISD

Other (please be specific):

Height:

Weight:

Eye Color:

Hair Color:

Other physical characteristics:

Does your child have any allergies (food, bee stings, medicine)?:

Does your child have any limitations or conditions we should be aware of?: