Parent/Legal Guardian 1 Information
First and Last Name(required)
Help for First and Last Name
First and Last Name
Street Address(required)
Help for Street Address
Be sure to add the house, building, or apartment number.
City
Zip Code
Phone Number(required)
Email Address
Parent/Legal Guardian 2 Information
First and Last Name
Street Address
Help for Street Address
Be sure to include the house, building, or apartment number.
City
Zip Code
School District(required)
Help for School District
Pick the District where you reside.
(Please Select)
Dansville
East Lansing
Haslett
Holt
Lansing
Leslie
Mason
Okemos
Stockbridge
Waverly
Webberville
Williamston
Email Address
CHILD 1 Information (under 5 years of age)
Child 1 First and Last Name(required)
Child 1 Date of Birth(required)
Child 1 Race (check all that apply)
Help for Child 1 Race (check all that apply)
Demographic data is based upon collected by grant funders
American Indian/Alaska Native
Asian American
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other
Child 1 Gender at Birth
Female
Male
Who does Child 1 reside with?
If Child 1 CURRENTLY has an Early On or GPGS Home Visitor, please list their name.
CHILD 2 Information (under 5 years of age)
Child 2 First and Last Name
Child 2 Date of Birth
Child 2 Race (select all that apply)
American Indian/Alaska Native
Asian American
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other
Child 2 Gender Assigned at Birth
Female
Male
Who does the Child 2 reside with?
If Child 2 CURRENTLY has an Early On or GPGS Home Visitor, please list their name.
CHILD 3 Information (under 5 years of age)
Child 3 First and Last Name
Child 3 Date of Birth
Child 3 Race (check all that apply)
American Indian/Alaskan Native
Asian American
Black/African American
Hispanic/Latino
Native Hawaiian/Pacific Islander
White
Other
Child 3 Gender Assigned at Birth
Female
Male
Who does the child reside with?
If Child 3 CURRENTLY has an Early On or GPGS Home Visitor, please list their name.
Family Information
Primary Language Spoken in the Household
Does anyone in the family have a disability or delay? If yes, please explain. Is there additional information you would like us to know about your child(ren).
Where did you hear about our program?
Family
Friend
Library
Event (Zoo Days, etc.)
Website/Social Media
Childcare
Physician
Preschool/GSRP
Head Start
WIC
Ingham County Heath Dept.
Other
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