Childcare Waitlist Enrollment Form
Which program are you interested in?
(Required)
Infant program
Toddler program
Preschool program
Are you interested in a specific childcare site?
(Required)
Casa Childcare Center
Florence Childcare Center
Hope Childcare Center
King-San Pedro Childcare Center
McAlister Infant Toddler Center
Rita Walters Childcare Center
Vermont Childcare Center
Willowbrook Childcare Center
There is no specific center I'm interested in.
Do you currently have other children enrolled in any TCCI childcare sites? Select all that apply.
(Required)
Casa Childcare Center
Florence Childcare Center
Hope Childcare Center
King-San Pedro Childcare Center
McAlister Infant Toddler Center
Rita Walters Childcare Center
Vermont Childcare Center
Willowbrook Childcare Center
I don’t currently have any children enrolled in any TCCI childcare sites.
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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