California State Preschool & Center Based Child Care - Preliminary Application Page 3
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4ENROLLING CHILD INFORMATION
First Name ________________________ Middle Initial ______
Last Name __________________________
Date of Birth ______________________
Gender
! Male ! Female
Speak English
! Yes ! No
Primary Language ________________Race _____ Hispanic/Latino __Y __N
Child Relationship to Applicant ________________________________________________________________
Exceptional Needs:
The Chaffey College Child Development Center does not discriminate on the basis of sex, sexual orientation, gender,
ethnic group identification, race, ancestry, national origin, religion, color, or mental or physical disability in determining
which children are served.
Does any of the following apply to your child? ___Child Protective Services ___ Special Need / IEP / IFSP
___ Allergies / Foods / Medication ___Homeless ___Limited or Non-English ___Asthma ___Other
ALL OTHER FAMILY MEMBERS IN HOUSEHOLD (required)
1.
__________ ___________ ______________
2. __________ ___________ ________________
Name
Birth Date
Relationship
Name
Birth Date
Relationship
3. _________ ___________ ______________
4. __________ ___________ ________________
Name
Birth Date
Relationship
Name
Birth Date
Relationship
5. __________ ___________ ______________
6. __________ ___________ ________________
Name
Birth Date
Relationship
Name
Birth Date
Relationship
7. __________ ___________ ______________
8. __________ ___________ ________________
Name
Birth Date
Relationship
Name
Birth Date
Relationship
8. __________ ___________ ______________
10. __________ ___________ ________________
Name
Birth Date
Relationship
Name
Birth Date
Relationship
Total household family members: ________
CONFIRMATION INFORMATION
I swear under penalty of perjury that the above information is true and correct.
•
I hereby authorize agency staff to verify wages with my employer. In addition, I authorize the release and
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sharing of my files by legally authorized personnel from the agency, from California Department of Education, or
from Community Care Licensing to determine program compliance, family eligibility, and conformance with
regulations and reporting requirements.
I understand that this is a preliminary application ONLY and does not guarantee enrollment in the program.
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___________________________________
___________________
__________________________
Signature
Date
Relationship to Child
Pb:dt:prelimapp
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