CCAP Program Enrollment Freeze Waitlist (ENG)

CCAP

Adams County

CCAP Program Enrollment Freeze Waitlist

Who’s Eligible for the Adams County CCAP Enrollment Freeze Waitlist?

Adult caretakers and teen parents residing in Adams County.
Adult caretaker and teen parents participating in a qualifying activity:
- Employed/self-employed
- Job search
- Basic education (high school, GED program, English as a Second Language)
- Training (vocational or technical)
- Post-secondary education (up to first bachelor’s degree)
Adult caretakers and teen parents with a total gross household income less than the maximum monthly income outline below for their household size.

Family Size	2	3	4	5	6	7	8
Maximum Monthly Gross Income	$3,697.50	$4,661.25	$5,625.00	$6,588.75	$7,552.50	$8,516.25	$9,480.00

What is the Enrollment Freeze Waitlist Process and Requirements?

Applicants must submit a complete Pre-Screening Questionnaire for review.
Pre-Screening Questionnaires are processed in the order received.
Applicants are notified via email if approved or denied for the enrollment freeze waitlist. Approved applicants are placed on the enrollment freeze waitlist.
Wait-listed households are only eligible for enrollment freeze waitlist enrollment and are not eligible for the CCAP benefit.
Wait-listed households are required to complete a recertification every six months to determine the household’s eligibility to remain on the waitlist. These will be emailed to households. Wait-listed households should notify CCAP if their email address changes as communication and recertification are sent via email from CCAP.
Wait-listed households should visit the Adams County CCAP Website for program updates, additional information, and resources.
If space become available, eligible wait-listed households will be contacted via email to complete an application.

Questions? Check out our website at https://adcogov.org/colorado-child-care-assistance-program-cccap or email [email protected].

Enrollment Freeze Waitlist Pre-Screening Questionnaire (PSQ) All starred sections are (*) REQUIRED INFORMATION and must be completed or application may be denied.

*Applicant Name (Last, First, Ml):

Date:

*Home Address (street address, city, state, zip):

*Mailing Address (street address, city, state, zip):

*Are you homeless: Y/N

*Email address:

*Primary phone: Cell, Home, or Work

*Is there a second adult caretaker in the home: Y/N *If yes, additional caretaker information must be included.

Caretaker Information

*Primary Adult Caretaker Name:

*SSN:

*Date of Birth:

*Gender: Male/Female

*Employed or self-employed: Y/N *If yes, you must complete the employer’s name, start date, income, and hours worked.

Employer Name:

Start date:

Gross monthly income: $

Average Hours Worked Per Week:

If self-employed, select type: Sole proprietor, 1099 Contractor, LLC, S-Corp, Other:

*Attending school or training: Y/N *If yes, you must complete the school or training program name and start date.

School or Training Program Name:

Start date:

*Job Searching: Y/N

*Disabled: Y/N

Additional Adult Caretaker

*Additional Adult Caretaker Name:

*SSN:

*Date of Birth:

*Gender: Male/Female

*Relationship to primary adult caretaker:

*Employed or self-employed: Y/N *If yes, you must complete the employer’s name, start date, income, and hours worked.

Employer Name:

Start date:

Gross monthly income: $

Average Hours Worked Per Week:

If self-employed, select type: Sole proprietor, 1099 Contractor, LLC, S-Corp, Other:

*Attending school or training: Y/N *If yes, you must complete the school or training program name and start date.

School or Training Program Name:

Start date:

*Job Searching: Y/N

*Disabled: Y/N

Child(ren) Information

Child One

Needs Care: Y/N

Full Name

Date of Birth:

In School: Y/N

Special Needs: Y/N

SSN:

Gender: Male/Female

Relationship to Primary Adult Caretaker:

Child Two

Needs Care: Y/N

Full Name:

Date of Birth:

SSN:

Gender: Male/Female

Relationship to Primary Adult Caretaker:

In School: Y/N

Special Needs: Y/N

Child Three

Needs Care: Y/N

Full Name:

Date of Birth:

SSN:

Gender: Male/Female

Relationship to Primary Adult Caretaker

In School: Y/N

Special Needs: Y/N

Child Four

Needs Care: Y/N

Full Name:

Date of Birth:

SSN:

Gender: Male/Female

Relationship to Primary Adult Caretaker

In School: Y/N

Special Needs: Y/N

Child Five

Needs Care: Y/N

Full Name:

Date of Birth:

SSN:

Gender: Male/Female

Relationship to Primary Adult Caretaker

In School: Y/N

Special Needs: Y/N

Child Six

Needs Care: Y/N

Full Name:

Date of Birth:

SSN:

Gender: Male/Female

Relationship to Primary Adult Caretaker

In School: Y/N

Special Needs: Y/N

Additional Income

*Do you or any other household member receive any other type of income? Y/N

If yes, you must report the income type, amount and how often it is received (weekly, bi-monthly, monthly, etc.) Examples include but are not limited to child support, alimony, maintenance, unemployment, retirement benefits, Veterans benefits, military allotment, cash contributions, in-kind income, worker compensation, interest on savings/CDs, dividends on stocks/bonds, annuities, social security (survivor’s disability, retirement), supplemental security income (SSI) Income Type:

Income Type: Income Type, Amount, AND How Often Received

Assets

*Do you or the additional caretaker have any liquid resources or cash on hand? Y/N; *If yes, how much?

Do you or the additional caretaker have any non-liquid resources or non-cash resources? Y/N; *If yes, how much?

Child Support Paid Out

*Is anyone in your household paying court-ordered child support for a child not residing in your home? Y/N; *If yes, how much is paid out per month?

Notice and Acknowledgement of Data Sharing

By signing this document, I acknowledge and agree that in order to be remain on the wait list or potentially participate in and receive benefits and services through the Colorado Child Care Assistance Program ("CCCAP"), that my local County Department of Human Services (the "County") and the Colorado Department of Early Childhood ("CDEC") may need to share information about me with any of the entities listed below: • Any other governmentally-administered assistance program — including any entity directly involved in the administration or delivery of said governmentally-administered assistance program — including, but not limited to, Head Start, Early Head Start, and the Colorado Universal Preschool Program. I further acknowledge and agree that the County and CDEC may require information and documentation from the entities listed below to process my Enrollment Freeze Wait List Redetermination, to determine my waitlist eligibility, or to otherwise manage my CCCAP-reIated services. By signing this document, I hereby authorize the entities listed below to release information about me to the County and CDEC in order to participate in and receive benefits and services through CCCAP: • Any employer for whom I currently work or have worked, • Any documentation submitted for self-employment, • Any school or training institution I may be attending, • Any other governmentally-administered assistance program — including any entity directly involved in the administration or delivery of said governmentally-administered assistance program — including, but not limited to, Head Start, Early Head Start, and the Colorado Universal Preschool Program. By signing this document, I certify that the information on this form is correct, to the best of my knowledge. I understand that misreporting information or failing to complete the waitlist recertification process every six months may result in the removal from the waitlist. I have read and agree to the conditions outlined.

*Primary Caretaker Signature:

Sign above

Signature Date:

Additional Caretaker Signature:

Sign above

Signature Date:

Thank you for completing this form.

Department

Human Services

Keywords

CCAP Freeze Waitlist

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CCAP Program Enrollment Freeze Waitlist (ENG)

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