California State Preschool & Center Based Child Care - Preliminary Application
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4California State Preschool & Center Based Child Care – Preliminary Application
Enrollment Priorities:
1) 4- and 3-year-old recipients of CPS
2) Children enrolled in program last semester
3) 4-year-olds with the lowest income ranking
4) 3-year-olds with the lowest in come ranking
General Enrollment Priorities are established as follows: *Students enrolled at Chaffey College
*Chaffey College Employees
*Community Members
A – FIRST PARENT INFORMATION
(Parent ((p
First Name ________________________ Middle Initial ______
Last Name _________________________
Street Address (required) ______________________ City _____________County________ State __ Zip _____
Home Phone _____________________ Work Phone _________________ Okay to call work ! Yes ! No
Message Cell/Pager _________________ Best Place to Call ______________ Best Time to Call __________
E-mail address ____________________ Relationship to Child ___________________
Marital Status ! Single
! Married
! Divorced
! Separated
! Widowed
Date of Birth ______________________
Gender ! Male
! Female
Speak English ! Yes ! No Primary Language __________Race ________Ethnicity (Hisp/Latino) __Y __N
Please Check All that Apply To You:
! Chaffey College Student
ID # _____________________________
! Student enrolled at (Accredited School) _____________________________ ID # ________________
! Pell Grant Eligible ___Yes ___ No
Have you applied for the Pell Grant?
___ Yes ___ No
! Educational / Training Goal (Be specific) _______________________________________________
! Chaffey College Employee : ! Full-time ! Part-time Department _______________ Ext. _____
! Community Member (Full Cost applicant)
Are you currently receiving CalWORKs or participating in
! YES ! NO
CalWORKs activity?
Have you received AFDC, TANF, or CalWORKs Cash Aid
! YES ! NO
within the last 2 years?
If Yes to the question above, what was the last date that you
received aid or received one-time payment?
CalWORKs Cash Aid received each month (Please attach Notice
of Action)
Gross Monthly Wages received by First Parent each month
(Please attach pay stub)
Child Support Total Amount received by First Parent each month
(Please attach documentation)
Spousal Support total amount received by First Parent each
month (Please attach documentation)
Unemployment received by First Parent each month (Please
attach documentation)
Social Security (Not SSI/SSP) received by First Parent each
month (Please attach documentation)
SDI (State Disability Insurance) received by First Parent each
month (Please attach documentation)
Do YOU PAY Child Support each month? (Please attach
! YES ! NO
documentation)
If YOU PAY Child Support, is the child you are paying for
! YES ! NO
receiving subsidized child care?
Other Source of income per month. Please specify:
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