How to participate in Play and Learn GRCCEach child participating enrolls once for the program year, June1 through May 31.A child may attend any Play and Learn GRCC site with a single enrollment.A family with multiple children attending complete the enrollment form for each child through 5 years old.Play and Learn Spanish Enrollment FormSpanish Enrollment form instructions:Download the Play and Learn Spanish Enrollment Form PDF to your computer.Fill out the form.Save the form.Email the form to kathleenneumann@grcc.eduPlay and Learn GRCC Enrollment Form You must have JavaScript enabled to use this form. Child's Information Child's First Name Child's Last Name Child's Middle Name Suffix Suffix - Select -Jr.IIIIINoneOther… Enter other… Child's Date of Birth Child's Date of Birth: Date Child's Gender Identity Child's Gender Identity - None -MaleFemaleOther… Enter other… Child's Ethnicity - None -Not Hispanic or LatinxHispanic or Latinx Child's Race - None -WhiteBlack/African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialOther Child's Address Address Address 2 City/Town ZIP/Postal Code Child's Primary Insurance - None -MedicaidMedicarePrivate InsuranceUninsured Caregiver Information Primary Caregiver's First Name Primary Caregiver's Last Name Primary Caregiver's Middle Name Primary Caregiver's Suffix Primary Caregiver's Suffix - Select -Jr.Sr.IIIIINoneOther… Enter other… Is the primary caregiver the child's Legal Guardian? Yes No Primary Caregiver's Last Grade Completed - None -High school/GEDSome high schoolLess than high schoolAssociates (2 year)College (4 years)Some collegeGraduateDoctorate Primary Caregiver's Employment Status - None -Full timePart timeUnemployed Primary Caregiver's Marital Status - None -MarriedDivorcedSingleLiving together/partnerSeperatedWidowed Number of household members Number of Children Through Age of 5 in Household Household Income Range - None - Less than $20,000$20,000-$39,999$40,000-$59,999$60,000-$79,999$80,000-$99,999Over $100,000 Household Income (numerical) $ Household Primary Language English Spanish Other… Enter other… Primary Caregiver's email contact Primary Caregiver's phone contact What relationship do you have with the child(ren) you bring to Play and Learn. Select all that apply. Parent Family member providing care Friend or neighbor proving care Licensed Family/Group Child Care provider Unlicensed Registered Provider receiving childcare payment Nanny License/Registration Number Yes, I would like to receive training hours. No, I would not like to recieve training hours. Child Care Providers are eligible to receive training hours that may increase their level of reimbursement. By providing your license/registration number, you are giving GRCC permission to enter your training hours into MiRegistry. License/registration number Required This field is required Childcare providers must be registered in MiRegistry to receive training hours. I would like to enroll another child. Yes No Second Child's Information Child's First Name Required This field is required Child's Last Name Required This field is required Child's Middle Name Suffix Suffix - Select -Jr.IIIIINoneOther… Enter other… Required This field is required Child's Date of Birth Required This field is required Child's Date of Birth: Date Child's Gender Identity Child's Gender Identity - None -MaleFemaleOther… Enter other… Child's Ethnicity - None -Not Hispanic or LatinxHispanic or Latinx Child's Race - None -WhiteBlack/African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialOther Child's Address Address Address 2 City/Town ZIP/Postal Code Required This field is required Child's Primary Insurance - None -MedicaidMedicarePrivate InsuranceUninsured I would like to enroll another child. Yes No Required This field is required Third Child's Information Child's First Name Required This field is required Child's Last Name Required This field is required Child's Middle Name Suffix Suffix - Select -Jr.IIIIINoneOther… Enter other… Required This field is required Child's Date of Birth Required This field is required Child's Date of Birth: Date Child's Gender Identity Child's Gender Identity - None -MaleFemaleOther… Enter other… Child's Ethnicity - None -Not Hispanic or LatinxHispanic or Latinx Child's Race - None -WhiteBlack/African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific IslanderMulti-RacialOther Child's Address Address Address 2 City/Town ZIP/Postal Code Required This field is required Child's Primary Insurance - None -MedicaidMedicarePrivate InsuranceUninsured Consent I give permission for myself/my child's photos, drawings or voices to be used for printed materials, videos, and/or training sessions by Grand Rapids Community College. Yes No Required This field is required I give permission for GRCC to use my contact information for programming purposes such as sending newsletters, surveys, and program updates. Contact information will not be shared with others. Yes No Required This field is required I give permission for GRCC to share aggregate demographic data with additional funders to maintain program funding. Yes No Required This field is required I give permission for Play and Learn GRCC to share my information, as required by the Ready by Five Millage, with the Kent County Health Department, Kent ISD, and First Steps Kent for the purposes of community reporting, program improvement and evaluation. Required Required This field is required Yes No Information Informed Consent: Kent County’s Ready by Five Millage is providing funding for Play and Learn GRCC. By providing your consent, you understand the following about services that are funded with Ready by Five Early Childhood Millage funds: Play and Learn GRCC is required to collect information about you and your child. Your information will be shared with the Kent County Health Department, Kent ISD and First Steps Kent for the purposes of community reporting, program improvement and evaluation. All reports made publicly available to the community by Play and Learn GRCC, Kent County Health Department and First Steps Kent will not name you or your child nor include any information that would allow people to determine that you or your child received a millage-funded service. The type of information that Play and Learn GRCC will be collecting for Ready by Five Millage reporting includes: · For child and parent/caregiver information including name, address, birth date, gender identity, race/ethnicity, health insurance type, education, employment status, marital status, household income, and primary language spoken. · Information on services received such as date, location, type of service, child development screening result received, and satisfaction with services. You may cancel this consent form at any time by sending a cancellation request in writing to Play and Learn GRCC at the following address: PAL@grcc.edu A Ready by Five Early Childhood Millage Privacy Notice is available on the GRCC website at: https://www.grcc.edu/business-community/laboratory-preschool/play-learn-grcc I have received/reviewed the Ready by Five Millage Privacy Notice Required This field is required