Apply (English)

* notes that fields are required

Parent A

*Number of parent and children under 18 living in the home

*First Name: *Middle: *Last Name:

*Phone: Alt Phone: Work:

*Date of Birth:

*Relationship to child: Mother Father Grandparent Guardian Foster Parent Other

*Marital Status: Married Single Widowed Divorced Separated

*Is English spoken in the home? Yes No - (If No what Language)

Ethnicity:

Reason child care/preschool services needed:
Working Employer's Zip Code
School/Training Training zip code
2nd Job Employer's zip code
Looking for work
Early education experiences
Incapacitation

Current Sources of Income (Report gross income before taxes and deductions)
Wages per month $
CalWORKs (Cash Aid) $
Child/Spousal per month $
Unemployment per month $
Disability per month $
Financial Aid $
Tips/Bonuses per month $
Other $
Parent A Monthly Total

Parent B

Number of parent and children under 18 living in the home

First Name: Middle: Last Name:

Phone: Alt Phone: Work:

*Date of Birth:

Relationship to child: Mother Father Grandparent Guardian Foster Parent Other

Marital Status: Married Single Widowed Divorced Separated

Is English spoken in the home? Yes No - (If No what Language)

Ethnicity:

Reason child care/preschool services needed:
Working Employer's Zip Code
School/Training Training zip code
2nd Job Employer's zip code
Looking for work
Early education experiences
Incapacitation

Address

*Mailing Address
*Zip Code where you want child care of preschool services
Elementary School closest to where you want child care of preschool services

Please list all children under 13 who need child care or preschool services for each child

Child 1

*Gender Male Female

*First Name: *Middle: *Last Name:

*Bith Date: Ethnicity:

Does child have IEP (Individual Education Plan) or IFSP (Individual Family Service Plan)? Yes No
If yes please list:

Is Child Currently enrolled in any child care or preschool program that is funded by state or federal funds: Yes No
If yes please list:

Preferred program: Any available program State Preschool Head Start Full Day Child Care Center Subsidized Child Care Voucher Program/AP
*Zip code where you would prefer care:

*Schedule: Full Time(6 hrs.+) Part Time (less than 6 hrs.) Evenings Weekends

Child 2

Male Female

First Name: Middle: Last Name:

Bith Date: Ethnicity:

Does child have IEP (Individual Education Plan) or IFSP (Individual Family Service Plan)? Yes No
If yes please list:

Is Child Currently enrolled in any child care or preschool program that is funded by state or federal funds: Yes No
If yes please list:

Preferred program: Any available program State Preschool Head Start Full Day Child Care Center Subsidized Child Care Voucher Program/AP
Zip code where you would prefer care:

Schedule: Full Time(6 hrs.+) Part Time (less than 6 hrs.) Evenings Weekends

Child 3

Male Female

First Name: Middle: Last Name:

Bith Date: Ethnicity:

Does child have IEP (Individual Education Plan) or IFSP (Individual Family Service Plan)? Yes No
If yes please list:

Is Child Currently enrolled in any child care or preschool program that is funded by state or federal funds: Yes No
If yes please list:

Preferred program: Any available program State Preschool Head Start Full Day Child Care Center Subsidized Child Care Voucher Program/AP
Zip code where you would prefer care:

Schedule: Full Time(6 hrs.+) Part Time (less than 6 hrs.) Evenings Weekends

Child 4

Male Female

First Name: Middle: Last Name:

Bith Date: Ethnicity:

Does child have IEP (Individual Education Plan) or IFSP (Individual Family Service Plan)? Yes No
If yes please list:

Is Child Currently enrolled in any child care or preschool program that is funded by state or federal funds: Yes No
If yes please list:

Preferred program: Any available program State Preschool Head Start Full Day Child Care Center Subsidized Child Care Voucher Program/AP
Zip code where you would prefer care:

Schedule: Full Time(6 hrs.+) Part Time (less than 6 hrs.) Evenings Weekends