Enter Infant Enrollment (up to 12 months)

Enter Toddler Enrollment (12 months to 2 years old)

Enter Two(2) year old Enrollment

Enter Preschool (3 years old to Kindergarten) Enrollment

Enter School-Age Enrollment

Total SR Enrollment ¹

Base Stabilization Subgrant Subtotal ²

Supplemental Stabilization Subgrant

Enter Zip Code for Physical Address of program

(a). Are you a Contracted School Readiness Provider?

Select One Yes No

If yes, please select CLASS Score Range

Select One None Exempt 0 - 3.99 4 - 4.99 5.00 +

4.0 or higher differential

5.0 or higher differential

(b). Do you offer Non-Traditional Hours (Nights, Weekends, etc.)?

Select One Yes No

(c). Do you agree to use at least 25% of total grant amount on staff? ³

Select One Yes No

(d). Are you Gold Seal Accredited?

Select One Yes No

Supplemental Stabilization Subgrant Subtotal

Stabilization Subgrant Total

¹ SR Enrollment will automatically calculate

² Children enrolled in Early Head Start/Head Start ONLY are not eligible and will not be included in the Base Stabilization Subgrant calculations

³ If (c) answered yes, total to be spent on Workforce Initiatives is: $0.0