ECEAP Site of Interest:
Enter the site name you are interested in from the ECEAP Location page.
First Choice:
Second Choice (if any):
Child's legal name (first, middle, last):
Child's Nickname:
Child's birth date (mm/dd/yyyy):
Child's Gender: Male Female
Is this child on an Individual Learning Program (IEP)? Yes No*
*If no, do you have any concerns about this child's development? Yes No
Is this child's family currently receiving Child Protective Services (CPS), Family Assessment Response (FAR), or similar Indian Child Welfare (ICW) services?
Yes No
Is this child in official foster care? This means there is a caregiver authorization from a state or tribe that says this is a foster care placement.
Yes No
Is this child in kinship care - with or without a grant, with a relative or suitable other?
Yes No
Housing (select one):
Rent or own an adequate residence
Doubled-up with another family for convenience, choosing to be close to family or friends, or choosing to save money for future plans
Doubled-up with another family due to loss of housing, economic hardship or similar reason
In an emergency or transitional shelter
Sleeping in a hotel, motel, car, park, campsite or similar location
Moving from place to place (couch surfing)
Inadequate housing such as no water, heat or electricity; excessive mold; no cooking facilities
Language: This child speaks (select only one):
Only English
Mostly English, and some of another home language
Some English, but mostly another home language
English and another language at age level (bilingual)
Only home language other than English
Child's first language:
Child's second language:
Is this child Hispanic/Latino? Yes* No
*If yes, please specify (i.e. Cuban, Mexican, Puerto Rican, Spanish, etc.):
What race(s) do you consider this child?
White Black or African American
Alaska Native* (be specific, i.e. Aleut, Eskimo-Inupiaq or Yupik, Tingit, etc.):
American Indian* (be specific, i.e. Colville, Cowlitz, Kalispel, Spokane, Tualip, etc.):
Asian* (be specific, i.e. Burmese, Cambodian, Chinese, Filipino Japanese, Korean, Mongolian, etc.):
Native Hawaiian or Pacific Islander* ( be specific, i.e. Fijian, Marshall Island, Native Hawaiian, Samoan, etc.):
Parent/Guardain #1 Name (first and last):
Parent/Guardian #1 birth date:
Parent/Guardian #1 Gender: Male Female
Parent/Guardian #2 Name (first and last):
Parent/Guardain #2 birth date:
Parent/Guardian #2 Gender: Male Female
Do you need an interpreter to communicate with English speakers?
Yes* No
*If yes, what language(s) do you speak?
Physical Street Address: Apt# City: Zip code:
Mailing Address (if different): Apt # City: Zip code:
Parent/Guardian #1 Email:
Parent/Guardian #2 Email:
Parent/Guardian #1 Phone Number: Parent/Guardian #2 Phone Number:
Child lives with:
One Parent/Guardian (Name):
Two Parents/Guardians in same household (make sure both parent names are listed above)
Two Parents/Guardians in two households (if this is checked, answer these questions to determine which parents' income and activities are counted for ECEAP eligibility. Both parents need to be listed above.)
Does one household have primary legal custody? Yes* No
If yes, which parent has primary legal custody?
Spouse of this parent, if any:
If no, does one parent receive child support payments from the other household? Yes No
If yes, which parent receives the child support payments? Spouse of this parent, if any:
If no, ECEAP will count the income from the legal parent/guardian for each household. Do not include their spouses.
Enter the legal parents' names here: Household 1:
Household 2 (Name):
Contact info for Household 2:
Physical Street Address: Apt# City: Zip:
Mailing Address (if different): Apt# City:
(be sure to complete the email and phone numbers above for parent/guardian #2)
Estimated Family Size: To establish family size for the purpose of determining federal poverty level, count all people who meet all of the following criteria:
- Living in the same household with the ECEAP child. (Exception: Do not include hosts of families temporarily sharing housing with relatives or others).
- Related to the parent(s) or legal guardian(s) by blood, marriage, or adoption. (Include the ECEAP child and the child's parent(s) in this count)
- Supported by the income of the parent(s) or legal guardian(s) of the ECEAP child. (Do not include household members age 19 or older who have earned or unearned income that covers half or more of their support)
For special rules to count family size when there is joint custody with no primary legal parent and no child support, contact an ECEAP staff member.
Exception: For children in foster or kinship/relative care, count only the children in foster care or covered by a payment from the state or a tribe for kinship/relative care.
Household 1 - Estimate family size, using the instructions above:
Household 2 (if applicable) - Estimated family size, using the instructions above:
Parent/Guardian Employment, Training, and Other Activities: Answer the following questions for each parent/guardian named above.
Name of Parent/Guardain #1
Is parent/guardian #1 emoloyed? Yes* No
*If yes, enter number of hours per week in paid work status:
*If yes, enter employer name and phone number or email:
Is parent/guardian #1 enrolled and attending school or job training? Yes* No
*If yes, enter the total number of hours per week when school is in session. Include class time, up to 10 hours of study time, and travel time:
*If yes, enter name of school or training organization:
*If yes, enter goal or major:
Is this parent/guardian #1 in an approved WorkFirst activity other than emoloyment, education or job training mentioned above?
Yes* No *If yes, describe activity:
*If yes, enter number of hours per week in approved activity and related travel:
Is family approved for child care through CPS, FAR or similar tribal funds?
Yes* No
*If yes, enter number of approved hours per week:
Parent #1 is disabled and unable to work and unable to care for the child while the other parent works?* Yes No
Name of Parent/Guardain #2
Is parent/guardian #2 emoloyed? Yes* No
*If yes, enter number of hours per week in paid work plus work-related travel:
*If yes, enter employer name and phone number or email:
Is parent/guardian #2 enrolled and attending school or job training? Yes* No
*If yes, enter the total number of hours per week when school is in session. Include class time, up to 10 hours of study time, and travel time:
*If yes, enter name of school or training organization:
*If yes, enter goal or major:
Is this parent/guardian #2 in an approved WorkFirst activity other than emoloyment, education or job training mentioned above?
Yes* No *If yes, describe activity:
*If yes, enter number of hours per week in approved activity and related travel:
Is family approved for child care through CPS, FAR or similar tribal funds?
Yes* No
*If yes, enter number of approved hours per week:
Parent #2 is disabled and unable to work and unable to care for the child while the other parent works? Yes No
Estimated Family Income
Enter the estimated total annual income received by this child's parent(s) or guardian(s) named above:
$
How did you find out about ECEAP?
DCYF (formerly DEL) website Community Event
Flyer Postcard ECEAP Employee
Word of Mouth Caseworker Media
Community Agency - Name of agency:
Other - Describe other:
Survey for statewide planning
If you could choose the length of day for your child's preschool, which is best for your child and family?
Please note, these options may not all be available in your community this year.
Part-Day - about three and a half hours, three or four days per week.
School-Day - about six hours, four or five days per week.
Working-Day - available all day (about 10 hours), all year, like a child care center.
Security Measure