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?
A
B
C
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)
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