Children Of Promise

Child 1

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Desired Start Date

Program Applying For *

Does this child have an IEP or have they been referred for special education evaluation? *

Annual Household Income *

Enter combined annual income up to $100,000. If over $100,000 enter 100000.

Household Size (total people in home) *

Please check any public benefits that you receive:

Is your family experiencing homelessness? *

Does the child have an IEP or have they been referred for special education evaluation? *

Has the primary caregiver completed high school / No GED? *

Was the parent a teen at birth or are they currently under 21? *

Child was born outside the US or has one or more parent/caregiver born outside the US? *

Is the child a foster child or adopted? *

Does the parent/caregiver primarily speak a language other than English at home? *

Is either one of the child's parents an active military service member? *

Has the child previously participated in a formal early learning program? *

Is the family currently receiving Brightpoint childcare subsidies? *

Is the child currently living with both parents or a single parent? *

Is the child enrolled in early intervention or do they have a sibling enrolled in early intervention or special education? *

Has the child experienced any history of abuse, neglect, or domestic violence? *

Are any members of the household experiencing mental illness, chronic, or terminal illness? *

Has there been any DCFS involvement with the family?

Is there a history of alcohol or drug abuse in the household?

Is the child being raised by a caregiver other than a parent (grandparent, relative, guardian)?

Has there been a recent death of a parent, sibling, or child in the immediate family?

Was the child low birth weight or diagnosed with failure to thrive?

Is a parent or primary caregiver currently incarcerated?

Pre-Enrollment Form