Preschool Application
Thompson Integrated Early Childhood Program
800 South Taft Avenue
Loveland, CO 80537
(970) 613-5052
Applying for the Early Childhood Program - How it Works
Preschool is available for Thompson School District students who are 3 or 4 years of age on or before October 1st. Students may qualify for free preschool under the Head Start or Colorado Preschool Program funding sources or families may pay tuition. Openings are limited.
Please complete the following information and submit this application to the Early Childhood offices. Upon receipt, we will contact you to discuss placement options, next steps and answer any questions you may have.
DATE ______
CHILD'S NAME ______Date of Birth ___/___/____
(First)(Middle) (Last)
NICKNAME ______Gender : MALE FEMALE
ADDRESS ______CITY ______ZIP______
MAILING ADDRESS ______CITY______ZIP______
HOME PHONE______CELL PHONE ______EMAIL______
Child Lives With Both Parents Mother Only Father Only Foster Parents Legal Guardians
(check one) Mother/Stepfather Father/Stepmother Shared Custody Relatives
What is the Child’s Primary Language? ______
MOTHER'S NAME ______
FATHER'S NAME ______
Number of times you have moved in the past year. ______
Does your child have a current/active □ IEP □ IFSP □ Private Therapy □ None
Previous preschools your child has attended______
Please check the site/s you are interested in: □ Berthoud El □ Berthoud/Turner □ Carrie Martin □ Centennial □ Cottonwood Plains □ Coyote Ridge □ Edmondson□High Plains□ Lincoln □ Madison □ Monroe □ Ponderosa □ Sarah Milner □ Winona
OVER PLEASE
If you are interested in applying for the Head Start or Colorado Preschool Program, please complete the following:
Check if any of these descriptions fit your present situation:
□ no permanent home □sleep in a car, camper
□ sleep at a shelter □ stay in a motel
□stay with relatives/friends due to economic hardship □ own, rent a home or apartment
Mother:
Last grade attended school ______Received diploma or GED certificate? YES ____ NO ____
Father:
Last grade attended school ______Received diploma or GED certificate? YES ___ NO ____
Are you attending school now?
Mother__Yes __No__Full Time__Part time Where______
Father__Yes__No__Full Time__Part timeWhere______
Are you employed now?
Mother__Yes__No__Full time__Part timeWhere______
Father __Yes__No__Full time__Part timeWhere ______
What health insurance do you have for child? ______
What dental insurance do you have for child? ______
Many families receive services or financial assistance from one or more programs or agencies.
Does your family receive any of the following types of services or financial assistance? Check all that apply:
__Medical assistance (Medicaid/Medicare) __Unemployment insurance
__Food Stamps (SNAP) __Public housing (Section VIII, Angel House,etc)
__Public Assistance/Welfare (TANF)__Utility assistance
__WIC__ Project Self Sufficiency
__Supplemental Security Income (SSI)__Child support (alimony)
__Foster care/Adoption subsidy__ Work Force
__Mental Health__Workman's Compensation
__CCAP or other Child Care Assistance
__Other : Specify ______
Annual Family Income: Please check one:
___ Below $ 25,000
___ $25,000- $35,000
___ $35,000- $45,000
___ $45,000- $55,000
___ Above $ 55,000
____Total Household Family Members
Thompson School District is an equal opportunity educational institution and will not discriminate on the basis of race, color, national origin, gender and disability in its activities, program or employment practices as required by Title VI, Title IX and Section 504. For information regarding civil rights or grievance procedures, contact the Executive Director of Human Resources, 800 South Taft Avenue, Loveland, Colorado, 80537 (970) 613-5008 or the Office of Civil Rights, U.S. Department of Education, Region VIII, Federal Office Building, 1244 North Speer Boulevard, Suite 310, Denver, Colorado, 80204, (303) 844-2991
Revised 01/04/2016