Form Center

2. Health & Human Services

   Ph: (970) 641-3244 | Fax: (970) 641-3738
   220 N. Spruce St, Gunnison, CO 81230
   https://www.gunnisoncounty.org/ecc

3. 

5. EC Credential Stipend

9. First Name*
10. Last Name*
12. Mailing Address*
14. Contact Phone
15. Contact Email
17. Do you work for a licensed early childhood center or family childcare home?*
    -- Select One --YesNo

    Additional form entries will be shown based on your answer.

21. Funding and Suports are available if you are interesting in obtaining a childcare license.

    Are interested in becoming a licensed early childcare provider? By checking Yes below we will contact you using the above information to get you started.

    1. Yes
    2. No
23. Questions

    If you have any questions please submit them here. When our team reviews your submission they will reach out and provide answers to those questions if you requested to be contacted.

25. Employer Information
    -- Select One --Gunnison RE-1J Preschool (Lake School)TenderfootWonderland Nature SchoolLittle Red SchoolhouseParadise PlaceStepping StonesHinsdale County School District RE-1 (Community School)Wee CareMarble Sprouts PreschoolFamily Home Care ProviderOther (Self Employeed / Provide Information Below)

    Please select your current employer from the below options. If you select "Family Home Care Provider" or "Other" you will be required to fill out additional information below.

27. Childcare Center Name
28. Childcare Center License Number
30. Childcare Center Address
32. PDIS and Credential Information

    Stipends will be issued based on credential level as of November 2022.
    ** Educator Self Assessment and Professional Development Plan must be complete to receive the stipend.
    Level 1: $100  |  Level 2: $200  |  Level 3: $300  |  Levels 4 - 6: $400

    For individuals applying for the second year in a row:

    Level 1: $200  |  Level 2: $400  |  Level 3: $600  |  Levels 4 - 6: $800

34. Are you registered in Colorado's Professional Development & Information System (PDIS)?

    1. Yes
    2. No
35. Have you completed the educator self-assessment in PDIS?

    1. Yes
    2. No
37. What is your current Early Childhood Credential 3.0 Level?
    -- Select One --0 / Have Not Applied12345+
41. Tax Information

    Please fill out and attach a W9 for possible tax purposes. Use the link to the right to download a W9 from the IRS website.

42. W9 Download
    IRS W9 Webpage

    (Opens in new window)

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field