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Child's Date of Birth

Number of people in family

Child's Primary Language

Primary Parent's Language

** You may select full-day ONLY if you have been approved for CCCAP and you are in school or work full-time during the day.
** You may need to commit to the option enrolled for the remainder of the program year.
** CCCAP status will be verified

Choose all that apply

Parent(s) were age 19 or under when child was born Yes No

Child is in Foster Care Yes No

Child is in a group home Yes No

Child lives with non-parent guardian (i.e. grandparents, aunt/uncle) Yes No

Other parent is incarcerated Yes No

One or both parents are disabled Yes No

Family is currently homeless Yes No

If yes, please select: Please bring in copy of the 1st page of IEP/IFSP. Or fax to (303)355-3718

Other - Please Describe

Parent lacks health insurance Yes No

Parent diagnosed as a high risk pregnancy Yes No

Parent has had previous high risk pregnancy Yes No

Substance Abuse (smoking, including second hand smoke, alcohol, drugs) Yes No

History of depression, currently receiving treatment for depression Yes No

Domestic Violence Yes No

Mother's first language is not English Yes No

Currently not receiving prenatal care Yes No

Parent in last trimester of pregnancy Yes No

First time parent Yes No

This child is currently in the Clayton Infant/Toddler program Yes No

This child is currently in the preschool home-based program Yes No

This child is 4 years old Yes No

My other child attends Clayton Educare Yes No

This child is in another Early Head Start or Head Start program Yes No

If yes, name of center

Family has CCCAP for child Yes No

Child Protective Services is involved with this child Yes No

Relationship to Child

Security Code (above):

Programs/Services

Programs and Services

Educare

Institute

Pre-enrollment Form