Childcare Waitlist Enrollment Form
Which program are you interested in?
(Required)
Infant program
Toddler program
Preschool program
Parent/Guardian Information #1
First & Last Name:
(Required)
Email
What is your home language?
(Required)
English
Spanish
Other
Phone Number:
(Required)
Address
Street Address
City
ZIP / Postal Code
Which describes your household?:
(Required)
Single parent/guardian
Two parents/guardians
Foster parent
Other
Parent/Guardian Information #2
First & Last Name:
Email:
Home language:
English
Spanish
Other
Phone Number:
Reasons for Needing Childcare:
Check all that apply.
Parent/Guardian #1:
(Required)
Working
Attending school/job training
Seeking employment
Incapacitated
Homeless/seeking housing
Part-day educational preschool experience for your child(ren)
Parent/Guardian #2
Working
Attending school/job training
Seeking employment
Incapacitated
Homeless/seeking housing
Part-day educational preschool experience for your child(ren)
CalWORKs Participation (Cash Aid)
Are you currently receiving cash aid?
(Required)
Yes
No
Days & Hours of Employment:
Indicate the hours worked on the days listed (i.e. 8am – 4pm). If no hours are worked, leave blank.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Add
Remove
If you’d like to add hours worked for a second parent/guardian, click the (+) sign to add a second row.
Days & Hours of School/Training:
Indicate the hours spent at school or job training (i.e. 8am – 4pm). If no hours are worked, leave blank.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Add
Remove
If you’d like to add school or training hours for a second parent/guardian, click the (+) sign to add a second row.
Total Gross Monthly Income:
If more than one parent/guardian, please list individual gross monthly income of each parent/guardian.
Parent/Guardian #1:
(Required)
Parent/Guardian #2:
Children Living in the Home
List all children under 18 who are members of the family.
Child #1 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #1:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #2 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #2:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #3 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #3:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #4 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #4:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #5 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #5:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #6 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #6:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #7 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #7:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #8 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #8:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #9 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #9:
Full-time
Part-time
CPS/At risk
Foster child
IEP
Child #10 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Check all that applies to Child #10:
Full-time
Part-time
CPS/At risk
Foster child
IEP
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