Childcare Waitlist Enrollment Form
Did you hear about us at The Taste of Soul on October 18th?
(Required)
Yes
No
Which person assisted you at The Taste of Soul?
Tameka Devine
Rosa Hernandez
Loretta Iberosi
Melissa Chavez
Patricia Anguiano
Dafne Avila
Fabiola Ruiz
Lucy Bryant
DaShawna Sims
Tammi Fowler
Natasha Stallworth
Tammy Mosby
Anel Anguiano
Karina Soto
Joyce Hernandez
Yarilen Diaz
Erika Valenzuela
Sonia Love
Guadalupe Ramirez
Nicolette Rogers
Rominique Johnson
Yenifer Montes
Laura Santos
Maribel Martinez
Mayra Carrillo
Rosalia Nava
Maria Salamanca
Which program are you interested in?
(Required)
Infant program (6 weeks – 24 months)
Toddler program (18 – 36 months)
Preschool program (2-5 years)
Are you interested in a specific childcare site?
(Required)
Casa Childcare Center – 15711 S Atlantic Blvd, Compton, CA 90221
Florence Childcare Center – 7217 S Mace Place, Los Angeles, CA 90001
Hope Childcare Center – 3401 Somerset Dr, Los Angeles, CA 90016
King-San Pedro Childcare Center – 3817 S San Pedro St, Los Angeles, CA 90011
McAlister Infant Toddler Center – 4525 Pinafore St, Los Angeles, CA 90008
Rita Walters Childcare Center – 932 W 85th St, Los Angeles, CA 90044
Vermont Childcare Center – 10441 S Vermont Ave, Los Angeles, CA 90044
Willowbrook Childcare Center – 12829 S Jarvis Ave, Los Angeles, CA 90061
I’m not currently interested in a specific site.
Do you currently have other children enrolled in any TCCI childcare sites? Select all that apply.
(Required)
Casa Childcare Center – 15711 S Atlantic Blvd, Compton, CA 90221
Florence Childcare Center – 7217 S Mace Place, Los Angeles, CA 90001
Hope Childcare Center – 3401 Somerset Dr, Los Angeles, CA 90016
King-San Pedro Childcare Center – 3817 S San Pedro St, Los Angeles, CA 90011
McAlister Infant Toddler Center – 4525 Pinafore St, Los Angeles, CA 90008
Rita Walters Childcare Center – 932 W 85th St, Los Angeles, CA 90044
Vermont Childcare Center – 10441 S Vermont Ave, Los Angeles, CA 90044
Willowbrook Childcare Center – 12829 S Jarvis Ave, Los Angeles, CA 90061
I don’t currently have any children enrolled in any TCCI childcare sites.
Parent/Guardian Information #1
First & Last Name:
(Required)
Email
(Required)
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 (mental or physical disability)
Homeless/seeking housing
Currently living in a shelter
Part-day educational preschool experience for your child(ren)
Parent/Guardian #2
Working
Attending school/job training
Seeking employment
Incapacitated
Homeless/seeking housing
Currently living in a shelter
Part-day educational preschool experience for your child(ren)
Child Needs
Check all that apply to the child being enrolled.
(Required)
Are you interested in full-time? (4 or more hours)
Are you interested in part-time? (less than 4 hours)
CPS/At risk
Foster child
IEP (ages 3 and up)
IFSP (ages birth to 3)
Special needs
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:
(Required)
Gender
(Required)
Female
Male
Other
Date of birth
(Required)
MM slash DD slash YYYY
Child #2 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #3 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #4 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #5 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #6 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #7 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #8 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #9 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
Child #10 – First & last name:
Gender
Female
Male
Other
Date of birth
MM slash DD slash YYYY
How did you hear about us?
(Required)
Δ