Early Childhood Programs Application Form
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4The Campagna Center
Early Childhood Programs
PRIMARY PARENT/GUARDIAN INFORMATION
Primary Parent/Guardian First Name: __________________
MI: ______
Last Name: ___________________
Gender:
Male
Female
*Birth Date: __________________
Contact Information:
Employer/School Name: _______________________________Work Phone Number: ____________________________
Work Address: ___________________________City: _________________ State: ______ Zip Code: ____________
Home Address: ___________________________City: __________________ State: _____ Zip Code: ____________
Home Phone: _________________________
Cell Phone: ______________________
Email Address: ___________________________________________________________
*Receiving WIC:
Receiving TANF:
Yes
No
Previously
Yes
No
Previously
*Receiving Food Stamps (SNAP)
Yes
No
*Primary Language: _________________________
*Secondary Language: _____________________________
Latino *Race:
Asian
Bi-Racial/Multiracial
Black/African American
*Ethnicity:
White
Native American/Alaskan
Pacific Islander/Hawaiian
Other
Unspecified
th
*Education Level:
9
Grade or less
High School Graduate
Associate’s Degree
th
10
Grade
GED
Bachelor’s Degree
th
11
Grade
Training Certificate
Master’s Degree
th
12
Grade
Some College
Doctoral Degree
*Education Completion Date: ______________
*Completed a job training program, professional
certificate or license.
*Program Completion Date: ____________________
If in school/training, where? _______________________________________________________________________
*Veteran of the US military?
*Member of US military on active duty?
Yes
No
Yes
No
Employment Status:
Employed full time
Employed part time
Self-employed
Retired or Disabled
Unemployed
Training or in school FT
Training or in school PT
*Family Structure:
Single Parent
Two Parent
*# in Family: _________
*# in Household: _______
*Does the Primary Parent have Health Insurance?
Yes
No
*Name of Insurance ______________________
*Current Housing Status:
Homeless
Own
*Current Housing Date ___________________
Rent
Other
Homeless
Own
Rent
Other
*Previous Housing Status
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