22-23 Colorado Preschool Program Eligibility Checklist

22-23 Colorado Preschool Program Eligibility Checklist

Child's Full Legal Name*

Child's Birthdate*

Parent Name*

Please check all the following that apply and provide and explanation when possible.

All Information will remain confidential.

Developmental/Medical Concerns*

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If you checked an option in Developmental/Medical, please list your concerns:

Income Eligibility

Please check the box next to the income description that best applies to your household:

Household size = 1

Yearly income: $25,142

Monthly income: $2,096

weekly income: $484

Household size = 2

Yearly income: $33,874

Monthly income: $2,823

Weekly Income: $652

Household size = 3

Yearly income: $42,606

Monthly income: $3,551

Weekly Income: $820

Household size = 4

Yearly income: $51,338

Monthly income: $4,279

Weekly Income: $988

Household size = 5

Yearly income: $60,070

Monthly income: $5,006

Weekly Income: $1,156

Household = 6

Yearly income: $68,802

Monthly income: $5,734

Weekly Income: $1,324

Household = 7

Yearly income: $77,534

Monthly income: $6,462

Weekly Income: $1,492

Household = 8

Yearly income: $86,266

Monthly income: $7,189

Weekly Income: $1,659

None of the above incomes apply to my household

Parenting Challenges

Please select all that apply

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Is English a second language for your child?*

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Language spoken in the home:*

Are you currently receiving Child Care Assistance from any agency, and if so, with whom? (Colorado Works, CCCAP, private sources, etc.)*

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Social and Language Skills

For the next 7 questions, please rate your child on social and language skills.

Note: All children have periods of showing any of these behaviors and certainly, we're talking about 3 or 4 year olds who are naturally active, with limited attention spans, have some degree of trouble following directions, and get frustrated at times.

You would check one of these areas if your child shows any of these behaviors to a greater degree when you compare him or her with other children of the same age.

Finds difficulty in expressing themselves with words*

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Speaks but is not understood by everyone*

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Is often aggressive with other children*

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Easily distracted from a task*

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Cannot follow 2 step directions*

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Appears withdrawn*

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Easily frustrated*

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Other:

Please let us know what other circumstances may be occurring in your child's life that you believe may affect his/her learning. Examples of issues in this category may be a recent separation or divorce, a death of someone close to your child, one parent forced to live away from the family for work, incarceration, or military deployment, COVID-19 related stresses, or a mental or physical illness of someone in your family. You may attach supplemental documentation or speak directly with the CPP Administrator at 970-247-5411 ex. 1468

School your child will attend for kindergarten*

Preschool requested*

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Federal Ethnic Category:*

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Federal Race Designation:*

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Parent address*

Phone number*

Parent signature*

Signature date*

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