ECE 3 Year Old: 2012-2013 School Year (Round 2)

Please fill out the form completely.

Please make sure that you sign and date the last page. The form must have a parent/guardian signature for processing. If
you have any questions, please refer to the SchoolChoice Enrollment Guide or contact the Application Management
Department at 720-424-2625.

DPS Student ID #:
STUDENT INFORMATION
Students Name : Last First Middle Name No Middle Name Male
Female

Students Primary Home Address: Apt # City State Zip

Phone Number: Birth Date: (mm/dd/yyyy) Current Age: Birth Country:

/ /
This information is required by federal law, failure to answer questions will result in use of prior racial/ethnic data or an observer identifying for you.
Is your student Hispanic or Latino? Yes No
Race: (select all that apply) American Indian or Alaskan Native Asian Black or African American
Native Hawaiian or Pacific Islander White

PARENT/GUARDIAN CONTACT INFORMATION

With Whom Does the Student Live? (check one)
Both Parents Mother Only Father Only Mother and Stepfather Father and Stepmother
Foster Parents (need additional documentation) Relatives:______________________________________________
Other:______________________________________

#1 Parent/Guardians Name: Last First Middle Initial Relationship to Student:

#1 Parent/Guardians Home Phone Number:_______________________ #1 Parent/Guardians Cell Phone Number:______________________

#1 Parent/Guardians Work Phone:_____________________________ #1 Parent/Guardians Email:_____________________________________
I have the same address as Students primary address noted above.
I have a different address from the Students primary address (If different, please add the Parent/Guardian address below:
#1 Parent/Guardians Primary Home Address: Apt # City State Zip

In the event of an emergency, please contact this person First Second

#2 Parent/Guardians Name: Last First Middle Initial Relationship to Student:

#2 Parent/Guardians Home Phone Number:_______________________ #2 Parent/Guardians Cell Phone Number:_____________________

#2 Parent/Guardians Work Phone:_____________________________ #2 Parent/Guardians Email:_____________________________________
I have the same address as Students primary address noted above.
I have a different address from the Students primary address (If different, please add the Parent/Guardian address below:
#2 Parent/Guardians Primary Home Address: Apt # City State Zip

In the event of an emergency, please contact this person First Second

SCHOOL USE ONLY ACCEPT WAITLIST FULL-DAY HALF-DAY Document Checklist: Please include the
following:
Application taken by (print name): ________________________________________________ School #_______
Proof of age
Date and Time application received: ________________________ Date Scanned to TBAM: _____________________
Proof of address (with service address)
Copy given to parent/guardian Address verified in IC Stated income
Is the applicant qualified or applying for any of the following (check all that apply): Household size
Student has IEP Retained

Application Management Department 720-424-2625 http://earlyeducation.dpsk12.org/ Page 1 of 3

 ECE 3 Year Old: 2012-2013 School Year (Round 2)

3 YEAR OLD PRESCHOOL PROGRAM PREFERENCE

Please fill in the box with the program that you would like your child to attend

Name of School/Program: _____________________________________________________________________

I prefer:
Full Day Class

Half Day Class

(please note that requests for AM/PM programs can only be accommodated per schools availability)

LANGUAGE
What language is primarily spoken in the home?
English Spanish Vietnamese Arabic Russian Other: _____________________
What is the students native language?
English Spanish Vietnamese Arabic Russian Other:____________________
In which language would you prefer your child be taught? (check one) English Spanish
Please complete the HLQ Form included in this packet!

EMERGENCY CONTACT INFORMATION

If we are unable to reach the students parent(s)/guardian(s) in an emergency, we will call the emergency contacts listed below.

Name:_____________________________________________________ Relationship to Student:__________________________________

Home Phone:______________________________ Work Phone:__________________________ Cell Phone:_________________________
Additional Information:_____________________________________________________________________________________________
In the event of an emergency, please contact this person First Second

Name:_____________________________________________________ Relationship to Student:__________________________________

Home Phone:______________________________ Work Phone:__________________________ Cell Phone:_________________________
Additional Information:_____________________________________________________________________________________________
In the event of an emergency, please contact this person First Second

Application Management Department 720-424-2625 http://earlyeducation.dpsk12.org/ Page 2 of 3

 ECE 3 Year Old: 2012-2013 School Year (Round 2)

TUITION INFORMATION AND HOUSEHOLD SIZE

I do not wish to disclose my income information and I agree to pay full tuition
I do not live in Denver County and will not qualify for tuition assistance
I am requesting tuition assistance and have completed the information below
(Please note: In order to calculate accurate tuition assistance, the number of household members and an income amount must be completed below. If you do not
complete all of the needed information, your application will be deemed incomplete and you could be charged full rate tuition.)
Name of Parent/Guardian Monthly Gross Income Non-Work Monthly Gross Income Total Monthly Gross Work and
Most recent TANF, Child support, Alimony, Gross Non-Work Income
income/salary/wages Unemployment, Food Stamps, etc. (Amount before taxes)
(Amount before taxes)
$ $ $
$ $ $

$ $ $

Total Monthly Work Income: Total Monthly Non-Work Income: TOTAL INCOME:
$ $
$

HOUSEHOLD SIZE (Parent/Guardians+Children):

You may be chosen in a yearly audit and, if chosen, you will need to provide adequate documentation of the income stated above. If you are
unable to provide the documents supporting the income stated, your tuition level may be readjusted to a full-pay tuition amount.

Tuition Information and Agreement to Pay

I certify that all the above information is true and correct and that all income is reported. I understand this information is being given for the receipt of Federal and
State funds and that school officials may verify the information on the application & further agree to release my student(s) Free & Reduced Lunch status. I understand
that if I purposely give false information my child(ren) may lose the benefit garnered & that I may be prosecuted. I understand that I am responsible for the full tuition,
and agree to pay the monthly fee (as calculated by DPS Tuition, Billing and Application Management and which is based on my monthly income) once the school year
begins.

Parent Initials: ________________

General SchoolChoice Information and Agreement
I understand transportation is not provided for my child to and from pre-school.
I understand that pre-school is not guaranteed for any child in Denver Public Schools.
I understand that it is my responsibility to complete any required additional steps necessary to qualify for a program to which I would like
my child assigned, such as auditions, interviews, testing, etc.
I understand that if my child is not qualified for a program, he/she will not be enrolled in that program, even if I have listed that
school/program on this form. .
I understand that once enrolled in a school, it is my responsibility to abide by any school specific requirements.

Parent Initials: ________________

I understand that by signing this form, I agree to follow the enrollment process, I have read and agree to all information listed on
this form, that all information submitted on this form is accurate to the best of my knowledge, and I am accepting the resulting
assignment for my child.

Parent/Guardian Signature:_____________________________________________________ Date: __________________________

Parent/Guardian Printed Name: _________________________________________________

Application Management Department 720-424-2625 http://earlyeducation.dpsk12.org/ Page 3 of 3

 3 Year-Old Preschool Program Application Check List

APPLICATION CHECK LIST

The following documentation must be provided in order for Denver Public Schools to process your childs application. Only the items
listed on the checklist are acceptable forms of documentation. Incomplete applications cannot be processed.
Please ensure the following:
Completed Application Application is completed accurately
Sign and date necessary sections
You must provide an original, which will be copied, of one of the following:
Proof of Age Birth certificate
Baptismal record
Childs hospital record with official signature (nurse, doctor, hospital
registrar)
Passport
You must include a copy of one of the following:
Proof of Address Current lease
Current mortgage statement with property address
Current utility bill (Comcast, Xcel, Denver Water) with service
address
Completed Home Language Questionnaire (HLQ) Form (obtain from school)
Copy of childs immunization record

QUESTIONS?
If you have any questions about the preschool and kindergarten application process, please contact the Application
Management Office at 720.424.2639, option #2.
 201220133YEAROLDPRESCHOOL
TUITIONESTIMATES

FAMILIESMUSTLIVEINDENVERTOBEELIGIBLEFORTUITIONASSISTANCE.
NONDENVERRESIDENTSMUSTPAYFULLTUITION!

DenverPublicSchoolscosttoprovidepreschoolfor3yearoldsis$950permonthperchildforfulldayand$450permonthperchildfor
halfday.DPSisabletoprovidetuitionratesbelowcostbecauseofadditionalfundingsourcessuchasColoradoPreschoolProgram,Head
Start,andothers.Formoreinformationregardinghowtuitionratesaredetermined,pleasecontacttheEarlyEducationDepartmentat
(720)4242639orviewtheirwebsiteathttp://earlyeducation.dpsk12.org.

ThreeEasyStepstoDeterminetheTuitionRateforYourChild
1. Locatethenumberofpersonsinyourhouseholdinthefirstcolumn.
2. Onceyouvelocatedyourhouseholdsize,findyourtotalhouseholdgrossmonthlyincomeincolumnsA,B,C,D,orE.
3. Onceyouvedeterminedwhichcolumnholdsyourgrossmonthlyincome,movedowntotherowthatcontainstheprogramin
whichyouwishtoenrollyourchild.
4. Thisamountwillbethetuitionrateyoucananticipatepayingeachmonth.

Forexample:Ifyouhave4peopleinyourfamilyandyourhouseholdmakesagrossmonthlyincome(yourincomebeforetaxes)of$3,470,
whichislocatedincolumnB,andyouareenrollingyour3yearoldchildintoahalfdaypreschoolprogram,yourestimatedmonthlytuition
rateis$25.
YourtuitionratewillbeconfirmedbymailuponyourselectionbyDPS.Tomaximizetheamountoftuition
assistanceyouareeligibletoreceive,youMUSTsubmitallrequireddocumentation!

3YEAROLDPRESCHOOLTUITIONESTIMATES
Household A B C D E Non
Size Denver
Resident
&OptOut
Monthly Monthly Monthly Monthly Monthly AllMonthly
Gross Gross Gross Gross Gross Gross
Income Income Income Income Income Income
Levels

Upto From Upto From Upto From Upto GreaterThan

2 $2,268 $2,269 $2,942 $2,943 $3,678 $3,679 $4,168 $4,168.01
3 $2,857 $2,858 $3,706 $3,707 $4,633 $4,634 $5,250 $5,250.01
4 $3,446 $3,447 $4,470 $4,471 $5,588 $5,589 $6,333 $6,333.01
5 $4,035 $4,036 $5,234 $5,235 $6,543 $6,544 $7,415 $7,415.01
6 $4,623 $4,624 $5,998 $5,999 $7,498 $7,499 $8,497 $8,497.01
7 $5,212 $5,213 $6,762 $6,763 $8,453 $8,454 $9,580 $9,580.01
8 $5,801 $5,802 $7,526 $7,527 $9,408 $9,409 $10,662 $10,662.01

TUITION TUITION
PER TUITIONPER TUITIONPER TUITIONPER TUITIONPER PER
PROGRAM MONTH MONTH MONTH MONTH MONTH MONTH
ECE
3YearOld Tuition $30 $110 $195 $300 $400
HalfDay Free
Tuition
ECE
3YearOld Tuition $60 $220 $390 $600 $750
FullDay Free
Tuition
NonRefundableRegistrationFee(includedinfirstinvoice)
$0 $25 $35 $45 $50 $60