Greeleyschools



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 LastDate of Birth: ________________________ Gender: ?Male ?Female Month/Day/Year Physical Address: _________________________________________________________________ Street Address City State Zip CodeHome 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 ?NoIf yes, you may be asked to provide additional documentation. Section 3: Family InformationNumber 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 StartStaff 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 ?NoLanguages Spoken: ?English ?Spanish ?Other (Specify): _______________________________English Fluency: ?None ?Some ?Fluent Other language Fluency: ?None ?Some ?FluentLast 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 ?TrainingEmployer: _________________________________________________ Phone: _______________________Secondary Adult’s Name: _____________________________________ Date of Birth: _________________ First Middle Last Month/Day/Year Relationship to child: ______________________ Lives with the child: ?Yes ?NoLanguages Spoken: ?English ?Spanish ?Other (Specify): _______________________________English Fluency: ?None ?Some ?FluentOther language Fluency: ?None ?Some ?FluentLast 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 ?TrainingEmployer: _________________________________________________ Phone: _______________________Section 5: Income InformationWhat is your gross monthly income: How many people are supported by your income: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 NoDo 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?Was there any significant birth and developmental history?Are there any indirect family issues which include: substance/drug abuse, alcohol abuse, other abuse, medical issues or depression?Was child’s parent recently, currently, or going to be incarcerated?Is there any history of family learning problems?Do your school age children qualify for free or reduced-cost lunch?Was either biological parent of the child under 18 years of age and unmarried at the birth of the child?Do you have any concerns with your child’s ability to communicate verbally?Is the male in the household interested in Male Involvement Activities such as support groups, etc.?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 othersIn the past year, has your family moved? ?No ?Once ?Twice ?3 times or moreHave you been homeless in the past 12 months? ?Yes ?NoBy 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 DateGreeley Evans School District Early ChildhoodColorado Preschool Program (CPP)District 6 CPP is a community based preschool program at the following locations:#1 Child Enrichment Center - 4601 W 9th StABC at Scott Elementary - 3000 13th St. ABC at the Early Childhood Center on the Aims Campus- 55th Ave and 20th StABC East -1028 5th AveEarly Childhood University -2651 11th St Rd *NEW LOCATIONChild’s Name: ____________________________Parent’s Name__________________________Child’s Date of Birth: ______________________Phone Number __________________________Address_______________________________________________________________________Request for Colorado Preschool Program location for 2014-2015My first choice for preschool is :____________________________________________________My second choice for preschool is: _________________________________________________My third choice for preschool is:__________________________________________________Preferred Session: Morning AfternoonREMINDER: Due to our limited CPP slots at various locations requested location is NOT a guarantee of placement at that site.-------------------------------------------------------------------------------------------------------------------------------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. ................
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