TRIAD EARLY CHILDHOOD COUNCIL
Jump Start Child Care Subsidy Application
Last Name
M.I.
First Name
Street Address
City
State
Zip Code
County
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Annual Household Income (Ineligible if you qualify for CCAP)
Date you started employment, training or school
Children Information
Rows
Child 1
Child 2
Child 3
Child 4
Child Name
Date of Birth
Date of Enrollment
Weekly Tuition Rate
Child Care Program Name
License #
Child Care Contact Person
Child Care Provider Email
example@example.com
Colorado Shines Level of Provider
County where care is provided
Child Care Program Representative Signature (Triad can send to Child Care Representative after form is completed by applicant)
Date
/
Month
/
Day
Year
Date
Parent/Guardian Signature
Date
/
Month
/
Day
Year
Date
What are your plans for covering child care costs after the 3 month child care subsidy ends?
Funding provided by CIRCLE GRANT
Preview PDF
Submit
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