Greeley-Evans Community Preschool Application

Greeley-Evans Community Preschool Application

Greeley-Evans Community Preschool Application

Application Date: ______
How did you hear about Colorado Preschool Program or Head Start? ☐Enrolled before ☐Family ☐Friends ☐Referred by Agency ☐Flyer ☐Screening ☐Other: ______
Section 1: (Applicant) Child’s Information
Child’s Legal Name: ______
First Middle Last
Date of Birth: ______Gender: ☐Male ☐Female
Month/Day/Year
Physical Address: ______
Street Address City State Zip Code
Home Phone: ______Cell Phone: ______Other Phone: ______
Child’s Ethnicity: ☐Hispanic ☐Non-Hispanic
Child’s Race: ☐White ☐Black/African American ☐Native American ☐Native Hawaiian/Pacific Islander
☐Asian☐Chinese ☐Korean☐Vietnamese ☐Other: ______
Child’s Language: ☐English ☐Spanish ☐Other: ______
Does your child speak English? ☐None ☐Some ☐Fluent
Does your child speak other languages? ☐None ☐Some ☐Fluent
Section 2: Disabilities Information
Has your child been diagnosed with a disability or a developmental delay? ☐Yes ☐No
If yes, you may be asked to provide additional documentation.
Section 3: Family Information
Number in Household ___ Number in Family ___ Total number of children ___ Number of Children age 0-3 ___
Number of children age 4-5 ___
Indicate Family Type: ☐Two parent family (married or common law) ☐Foster Family
☐Single parent family: Child lives with ☐ Mom ☐Dad
☐Lives with Relative (Please Specify) ______

OFFICE USE ONLY

☐Colorado Preschool Program ☐Additional screening needed ☐Head Start
Staff person: ______
Print Name Program Date:
Section 4: Parent/Guardian Information
Primary Adult’s Name: ______Date of Birth: ______
First Middle Last Month/Day/Year
Relationship to child: ______Lives with the child: ☐Yes ☐No
Languages Spoken: ☐English ☐Spanish ☐Other (Specify): ______
English Fluency: ☐None ☐Some ☐Fluent
Other language Fluency: ☐None ☐Some ☐Fluent
Last Grade Completed:☐Less than 9th ☐Some High School ☐ High School Graduate ☐GED ☐College Degree ☐Other: ______
Occupation: ☐Unemployed ☐Employed Full Time ☐Employed Part Time ☐Seasonal ☐Temporary
☐School Full Time ☐School Part Time ☐Training
Employer: ______Phone: ______
Secondary Adult’s Name: ______Date of Birth: ______
First Middle Last Month/Day/Year
Relationship to child: ______Lives with the child: ☐Yes ☐No
Languages Spoken: ☐English ☐Spanish ☐Other (Specify): ______
English Fluency: ☐None ☐Some ☐Fluent
Other language Fluency: ☐None ☐Some ☐Fluent
Last Grade Completed:☐Less than 9th ☐Some High School ☐ High School Graduate ☐GED ☐College Degree ☐Other: ______
Occupation: ☐Unemployed ☐Employed Full Time ☐Employed Part Time ☐Seasonal ☐Temporary
☐School Full Time ☐School Part Time ☐Training
Employer: ______Phone: ______
Section 5: Income Information
1)What is your gross monthly income:
2)How many people are supported by your income:
3)Additional income:
Section 6: Assistance Information
☐TANF ☐Public Assistance (Food Stamps, WIC, etc.) ☐SSI Disability ☐None
Section 7: Other Information(If yes, please explain) / Yes / No
1)Do you have concerns about your child’s behavior;sleep/eating difficulty, low self-esteem, attention span, refusal behavior,or difficulty in play and interaction skills?
2)Was there any significant birth and developmental history?
3)Are there any indirect family issues which include: substance/drug abuse, alcohol abuse, other abuse, medical issues or depression?
4)Was child’s parent recently, currently, or going to be incarcerated?
5)Is there any history of family learning problems?
6)Do your school age children qualify for free or reduced-cost lunch?
7)Was either biological parent of the child under 18 years of age and unmarried at the birth of the child?
8)Do you have any concerns with your child’s ability to communicate verbally?
9)Is the male in the household interested in Male Involvement Activities such as support groups, etc.?
10)Is the child’s sibling attending another preschool program?
If yes please specify:
Section 8: Home/School Information
Who cares for your child when you are at work or at school? ______
☐Child Care Center (please specify): ______☐Relative or other adult in your home
☐Child Care Home (please specify): ______☐Relative or other adult in their home
☐Other: ______☐Elementary school of siblings: ______
Section 9: Housing Information
☐Housing/Public ☐Rent ☐Own ☐Safe-House ☐Living with others
In the past year, has your family moved? ☐No ☐Once ☐Twice ☐3 times or more
Have you been homeless in the past 12 months? ☐Yes ☐No

By signing this application, you grant Colorado Preschool Program and Head Start permission to share this application with each other. We will not share it with any other organization other than those mentioned above.

______

Primary Adult Signature Secondary Adult Signature Date

Greeley Evans School District Early Childhood

Colorado Preschool Program (CPP)

District 6 CPP is a community based preschool program at the following locations:

#1 Child Enrichment Center - 4601 W 9th St

ABC at Scott Elementary - 3000 13th St.

ABC at the Early Childhood Center on the Aims Campus- 55th Ave and 20th St

ABC East -1028 5th Ave

Early Childhood University -2651 11th St Rd *NEW LOCATION

Child’s Name: ______Parent’s Name______

Child’s Date of Birth: ______Phone Number ______

Address______

Request for Colorado Preschool Program location for 2014-2015

My first choice for preschoolis :______

My second choice for preschool is: ______

My third choice for preschool is:______

Preferred Session: Morning Afternoon

REMINDER: Due to our limited CPP slots at various locations requested location is NOT a guarantee of placement at that site.

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Return to Early Childhood Center on the Aims Campus

(Mailing Address-Preschool 1025 9th Ave Greeley CO 80631)

or ABC East 1028 5th Ave Greeley CO 80631.

Revised 3/2013