Thompson Integrated Early Childhood Program

Preschool Application

Thompson Integrated Early Childhood Program

800 South Taft Avenue

Loveland, CO 80537

(970) 613-5052

Applying for the Early Childhood Program - How it Works

Preschool is available for Thompson School District students who are 3 or 4 years of age on or before October 1st. Students may qualify for free preschool under the Head Start or Colorado Preschool Program funding sources or families may pay tuition. Openings are limited.

Please complete the following information and submit this application to the Early Childhood offices. Upon receipt, we will contact you to discuss placement options, next steps and answer any questions you may have.

DATE ______

CHILD'S NAME ______Date of Birth ___/___/____

(First) (Middle) (Last)

NICKNAME ______Gender : ¨ MALE ¨ FEMALE

ADDRESS ______CITY ______ZIP______

MAILING ADDRESS ______CITY______ZIP______

HOME PHONE______CELL PHONE ______EMAIL______

Child Lives With Both Parents Mother Only Father Only Foster Parents Legal Guardians

(check one) ÿ Mother/Stepfather ð Father/Stepmother Shared Custody Relatives

What is the Child’s Primary Language? ______

MOTHER'S NAME ______

FATHER'S NAME ______

Number of times you have moved in the past year. ______

Does your child have a current/active □ IEP □ IFSP □ Private Therapy □ None

Previous preschools your child has attended______

Please check the site/s you are interested in: □ Berthoud El □ Berthoud/Turner □ Carrie Martin □ Centennial □ Cottonwood Plains □ Coyote Ridge □ Edmondson □ High Plains □ Lincoln □ Madison □ Monroe □ Ponderosa □ Sarah Milner □ Winona

OVER PLEASE

If you are interested in applying for the Head Start or Colorado Preschool Program, please complete the following:

Check if any of these descriptions fit your present situation:

□ no permanent home □sleep in a car, camper

□ sleep at a shelter □ stay in a motel

□stay with relatives/friends due to economic hardship □ own, rent a home or apartment

Mother:

Last grade attended school ______Received diploma or GED certificate? YES ____ NO ____

Father:

Last grade attended school ______Received diploma or GED certificate? YES ___ NO ____

Are you attending school now?

Mother __Yes __No __Full Time __Part time Where______

Father __Yes __No __Full Time __Part time Where______

Are you employed now?

Mother __Yes __No __Full time __Part time Where______

Father __Yes __No __Full time __Part time Where ______

What health insurance do you have for child? ______

What dental insurance do you have for child? ______

Many families receive services or financial assistance from one or more programs or agencies.

Does your family receive any of the following types of services or financial assistance? Check all that apply:

__Medical assistance (Medicaid/Medicare) __Unemployment insurance

__Food Stamps (SNAP) __Public housing (Section VIII, Angel House,etc)

__Public Assistance/Welfare (TANF) __Utility assistance

__WIC __ Project Self Sufficiency

__Supplemental Security Income (SSI) __Child support (alimony)

__Foster care/Adoption subsidy __ Work Force

__Mental Health __Workman's Compensation

__CCAP or other Child Care Assistance

__Other : Specify ______

Annual Family Income: Please check one:

___ Below $ 25,000

___ $25,000- $35,000

___ $35,000- $45,000

___ $45,000- $55,000

___ Above $ 55,000

____ Total Household Family Members

Thompson School District is an equal opportunity educational institution and will not discriminate on the basis of race, color, national origin, gender and disability in its activities, program or employment practices as required by Title VI, Title IX and Section 504. For information regarding civil rights or grievance procedures, contact the Executive Director of Human Resources, 800 South Taft Avenue, Loveland, Colorado, 80537 (970) 613-5008 or the Office of Civil Rights, U.S. Department of Education, Region VIII, Federal Office Building, 1244 North Speer Boulevard, Suite 310, Denver, Colorado, 80204, (303) 844-2991

Revised 01/04/2016