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Application for Child Services
Completing this form does not guarantee enrollment. Your child will be kept on the waiting list for any open spaces. You are responsible to notify us of any changes in your contact information. This institution is an equal opportunity provider.
TODAYS DATE _______________________
START DATE (month/ year) _________________________
Parent/Guardians name __________________________________________
Childs name _____________________________ Birthdate ___/___/___
Address _______________________________City ___________Zip ________
Phone (day)________________ (eve)________________(cell)_______________
E-mail address______________________________________________________
Circle days interested in care-
M T W Th F
Flexible;#of days_______
depends on class scheduleCircle hours of interest-
7:45-5:15 (Full Day) 7:45-12:30 (Half Day)
7:45-2:30 (3/4 Day) 9:00-12:00 (Preschool Only) *Schedules for children will be determined by parents class schedules that are attending college.
IMPORTANT- For students only- Funded Program Eligibility Information-
This section must be completed in order to determine eligibility. If the child is enrolled at the Center, the income indicated will need to be verified upon enrollment. Monthly income includes all income received by the household including employment, child support, Welfare, Cal Works, Unemployment, Financial Aid/Grants, work income.
Family Size-_______Gross Monthly Income-________ You; _________ Spouse; ________ Other
income source TANF/CalWorks
Office Use Only
Date called-_______________ Initials-___________
Comments-
Date called-_______________ Initials-___________
Comments-
Priority # _________
Status (please check one)
Student ___
Staff/Faculty___
Community___
How did you hear about our Center?
____Friend ____Campus Referral ____WEB Site ____Student ____Other
S:Drive/Forms/ApplicationforSer
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