Form Lchs 4234 - Ccap Waitlist Pre-Eligibility Questionnaire

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CCAP Waitlist Pre-eligibility Questionnaire
(PEQ)
Applicant name (last, first, middle initial):
Home Address:
City, State, Zip Code:
Mailing Address:
City, State, Zip Code:
Daytime phone:
(
)
Message phone:
(
)
E-mail address:
How many children are in the household, including those who do not need child care?
How many of those children need child care?
How many parents are in your household?
Parent Information
Parent One Information:
Parent Two Information:
Name: ____________________________________
Name: _____________________________________
Social Security #: __________________________
Social Security #: ___________________________
Date of Birth:___________________
Date of Birth:___________________
Gender:
Male Female
Gender:
Male Female
Are you employed? Yes No
Are you employed? Yes No
If yes, where? ______________________________
If yes, where? ______________________________
Employment start date: ________________
Employment start date: ________________
Hourly wage: $_________________
Hourly wage: $__________________
Hours worked per week __________
Hours worked per week ___________
Are you in school? Yes
No
Are you in school? Yes
No
If yes, where? ______________________________
If yes, where? ______________________________
How many credit hours are you taking? __________
How many credit hours are you taking? __________
Please check any other activities you do :
Please check any other activities you do:
Job Searching
Work Study
GED
Job Searching
Work Study
GED
Job Training
Other: ______________
Job Training
Other: ______________
DEPARTMENT OF HUMAN SERVICES
Child Care Assistance Program
1501 Blue Spruce Drive
Fort Collins, CO 80524
LCHS 4234 (01/14)
(970) 498-6300
Fax (970) 498-7987

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