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Teller County Early Childhood Education (ECE) is federally funded (Early Head Start/Head Start) preschool program for income eligible children ages 0 to 5. Children attending Teller County Early Head Start and Head Start programs will engage in foundational learning experiences that will prepare them for school. Our rich play based environments provide a safe, secure, social setting that support the development of all children. Health and developmental screenings along with parent teacher conferences provide opportunity for parents to collaborate with staff for the development of their child. Healthy meals and snacks are part of the education experience. Parents are the primary educators of their children. We support them as an integral part of our program. Parent involvement in their child’s education will start here to form a foundation for involvement throughout their child’s school years. Teller County ECE supports parents and families in achieving their own goals, parent-child relationships and engaging in community. The following application questions, including income information, help us to determine if your family qualifies for services from our program. Please answer honestly and to the best of your ability. If you have any questions, please do not hesitate to contact Desi Patty at dpatty@ccvschools.com, (719)487-5866 or (719)689-3420. We look forward to meeting with you soon!

Fill out primary adult information completely below.

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

Email Address (Required)

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

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Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

SSN

Race

Hispanic

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Fill out full living address below.

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

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Mailing Address same as Living Address

Mailing Address

Address Line 2

City

State

ZIP

Fill out secondary adult information completely below.

Is there another parent/guardian in the family?

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender

Email Address

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Opt In for Text Messages

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Highest Grade Completed

Employment Status

Child's Relationship

Custody

Lives with Family

Provides Financial Support

Teen Parent

If Teen Parent, Subsidized?

Are there other adults in the household?

Add Another Adult

Fill out Family Information completely below.

Number of Parents/Guardians

Relationship to Participant(s)

Primary Language at Home

Is another language being acquired or learned at home?

Number in Household

Number in Family

Gross Annual Income

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program?

Is your family receiving Supplemental Security Income (SSI)?

Is your family receiving services from WIC?

WIC ID (if applicable)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps?

Is at least one parent/guardian an active duty member of the United States military?

Is at least one parent/guardian a veteran of the United States military?

Add Emergency Contact

Fill out applicant information completely below.

First Name (Required)

Middle Name

Last Name (Required)

Suffix

Nickname

Birthday (Required)

Gender

SSN

Race

Hispanic

English Proficiency

Other Language

Other Language Proficiency

Primary Health Coverage

Other Coverage

Insurance Number

Medicaid Eligibility

Medicaid Number

Doctor/Medical Home

Dental Coverage

Dental Coverage Number

Dentist/Dental Home

Does your child have a disability or do you have any concerns about your child's development?

Is there anything else you want to tell us about your child?

Which program are you applying for? (Required)

Location Preference

1st Location Preference

2nd Location Preference

3rd Location Preference

- Your Address - Available Locations

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Do you want to apply now for another child in your family?

Add Another Applicant

Are there other children in the family?

Add a Sibling

What Happens Next? As soon as we receive the completed application, we will review it and contact you to schedule an appointment. Please have the following documents ready for your follow up appointment: 1. Proof of birth (birth certificate, Passport or HMK Plus) 2. Immunizations 3. Most recent Well Child Check summary 4.Proof of Income (please provide one of the following): ?1040 Tax Return(from the previous calendar year) ?W2's (from the previous calendar year) ?Three Months Worth of Paystubs ?Proof of TANF or SSI ?Proof of Foster Placement 5. If applicable please provide the following: Unemployment Benefits, Court Ordered Paperwork pertaining to child being enrolled (custody papers, restraining orders, etc), Scholarships/Grants, or SSDI

Required information is missing, see above.

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings