Triad Early Childhood Council Jump Start Subsidy Application
*Please keep in mind that the review of applications will be delayed due to the holidays. Thank you for your patience.*
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian is starting a:
*
new job.
new school.
new training.
Start date of above activity:
*
Have you applied for Colorado Child Care Assistance Program (CCCAP)?
*
Are you receiving funding through Colorado Child Care Assistance Program (CCCAP)?
*
Household income:
*
$0-$30,000
$31,000-$60,000
$61,000-$90,000
$91,000-$100,000
Above $100,000
What county do you live in?
*
Colorado Shines Level of child care program:
*
Are you receiving UPK funding?
*
Anything else you want us to know?
Names and ages of children needing child care assistance?
*
Signature
*
Ethnic group:
*
Hispanic, Latino, or Spanish Origin
American Indian or other Native American
Asian American or Pacific Islander
Black/African American
White
Prefer not to answer
Other
Race:
*
American Indian or Alaska Native
Asian
Black or African American
White
Prefer not to answer
Other
# of people in the household:
*
# of children birth to 8 years of age:
*
Child care program:
*
Phone number of child care program:
*
License #:
*
Submit
Should be Empty: