Wayne County Board of Education Universal Pre-K Program

2026-2027 School Year Eligibility Application

Print PDF of Wayne County BOE Universal Pre-K Program

Wayne County Board of Education Universal Pre-K Program

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2026-2027 School Year Eligibility Application

Please Indicate Your First and Second Preschool Site.

* Indicates Before and After Care Offered On Site

First Choice | Choose the location of the center where the child is being enrolled*

(*) Indicates before and after care offered.

Second Choice | Choose the location of the center where the child is being enrolled

(*) Indicates before and after care offered.

A. Child Information

Child's Full Name*

Last Name Frist Name Middle Name

Child's Date of Birth*

SSN:*

Male or Female

Male

Female

Race

Native Language

Child's Physical Address*

Street Address City State ZIP Code

Child's Mailing Address

P.O. Box, or third-party service. City State ZIP Code

Child Resides with*

Birthplace*

City State

Language Spoken in Home

B. Parent or Guardian Information

Parent or Guardian Full Name*

Last Name Frist Name Middle Name

Date of Birth

Living in Home

Yes

Relationship

Race

Native Language

Guardian's Physical Address

Street Address City State ZIP Code

Guardian's Mailing Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Education Level

Please enter a number from 1 to 27.

Employer

Work Phone

C. Parent or Guardian Information

Parent or Guardian Full Name

Last Name Frist Name Middle Name

Date of Birth

Living in Home

Yes

Relationship

Race

Native Language

Guardian's Physical Address

Street Address City State ZIP Code

Guardian's Mailing Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Education Level

Please enter a number from 1 to 27.

Employer

Work Phone

D. Children Data: List Information For Other children In Household

Name

Last First

Date of Birth

Social Security Number

Choose One

Male

Female

Race

Native

Birthplace

Name

Last First

Date of Birth

Social Security Number

Choose One

Male

Female

Race

Native

Birthplace

Name

Last First

Date of Birth

Social Security Number

Choose One

Male

Female

Race

Native

E. Alternate Contacts: Please Provide At Least 2 People To Contact In The Event That Parents/Guardians Cannot Be Reached

First Contact Name

First Last

Address

Street Address City State ZIP Code

Phone

Second Contact Name

First Last

Address

Street Address City State ZIP Code

Phone

F. Educational History: Was Your Child Previously Or Currently Inrolled In Any Program Listed Below?

Early Head Start Location

Head Start Location

Child Care Location

Private Preschool/Other:

Are you in need of Child Care Services?

Yes

Does your child have a Birth to Three IFSP or School IEP?

Yes

G. Household Composition:

Please Indicate The Appropriate Selection

Homeless

Own

Rent (Unsubsidized)

Rent (Subsidized)

Living with Friends or Family

Transitional/Shelter

Other

H. Family Type

Please Indicate The Appropriate Selection

Grandparents Raising Child

Two-Parent Household

Single Parent Household

Other

Total Number of Adults

Please enter a number from 1 to 10.

Number of Children Under 18 Years Old

Please enter a number from 1 to 20.

How many are 3 years old?

Please enter a number from 1 to 10.

How many are 4 years old?

Please enter a number from 1 to 10.

Military

Yes, Active or Retired

None

If Yes, Military ID#:

I. Directions To Home

J. Adult Data. List Information For All Other Adults Living In Household, Not Mentioned Previously on Application

Name

First Last Relationship to Primary Parent or Guardian

Name

First Last Relationship to Primary Parent or Guardian

Name

First Last Relationship to Primary Parent or Guardian

K. Financial Information

Please complete the requested information below. The income information below will be evaluated according to the "Income Guidelines" established by the United States Department of Health and Human Services to determine Head Start eligibility. All information will be strictly confidential. If you meet eligibility guidelines and are interested in receiving additional support services, you will be asked to provide documentation that verifies the information provided by you.

Do you currently receive TANF funds (Temporary Aid for Needy Families) or in the past twelve months?*

Yes

Do you or any family members receive SSI payments (Supplemental Security Income)?*

Yes

Do you or any family members receive WIC Vouchers (Women, Infants and Children)?*

Yes

Do you or any family members receive SNAP?*

Yes

Do you or any family members receive any other type of assistance?*

Yes

If you are receiving one of these benifits please mark your annual income.

Please indicate annual income range of your household:

0-$22,200

$22,201-$27,969

$27,970-$36,499

$36,500-$43,649

$43,650-$50,799

$50,800-$57,999

$58,000-$65,099

$65,100-$72,249

Over $72,250

L. Signatures

Confidentiality Statement: All information above is requested for the application process. All Information must be completed to be considered. Applications missing information will be mailed back to Parent/Guardian to be completed and resubmitted. All information disclosed will be used only by those persons related to the program and who are on a need to know basis. Please initial each blank if you agree to the statement regarding the preschool program. Primary parent/guardian certifies that the information provided is accurate to the best of my knowledge. My child must attend the program regularly in accordance with the school district's attendance policy. Transportation to and from the program is not guaranteed. My child will need to participate in a variety of screenings prior to the school year beginning and during the school year. If enrolled, certificate of live birth, a current well child physical signed by a licensed physician, dental screening, and immunizations that are current are required.

Signature*

Type your name.*

Today's Date*