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Programs/Services

Programs and Services

Educare

Institute

Pre-enrollment Form

Use the form below to apply for enrollment.

Child Information:

Child's First Name

Child's Last Name

Gender male female

Child's Date of Birth

Today's Date

Number of people in family

Child's Primary Language

Primary Parent's Language

Classroom Options:

Click here to learn more about classroom options

Choice 1

Choice 2

** 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.
** CCCAP status will be verified

Child's Residence

Address

City

State

Zip

Phone

Alternate Phone

Primary Caregiver Information:

First Name

Last Name

Gender male female

Date of Birth

Income

Source of Income

Paid Every

School/Work Status

Secondary Caregiver Information:

First Name

Last Name

Gender male female

Date of Birth

Income

Source of Income

Paid Every

School/Work Status

Family

Parent(s)

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

Special Needs Is your child disabled or special needs?

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

Health Are your child's immunizations up to date?

Yes No

Does your child have health insurance? (CHP+, Denver Health, Medicaid, SSI or private insurance)

Yes No

Does your child have a current physical/well child?

Yes No

Status Choose all that apply

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

Childcare

Family has CCCAP for child Yes No

CCCAP Worker's Name

Child Protective Services is involved with this child Yes No

Reference

Referred by

Parent/Guardian

Relationship to Child

Security Code (above):