Concord Child Care Center Eligibility List

Family Information

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* 1. Today's Date

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* 2. Are you applying for:

All-day care because you are looking for work, working, or attending school.

Part-day preschool because your child will be attending Kindergarten the following year.

Other (please specify)

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* 3. What is your street address?

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* 4. Are you homeless or seeking permanent housing?

Yes

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* 5. Caregivers in Household (check all that apply)

Mother

Father

Legal Guardian

Step-Parent

Other (please specify)

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* 6. Primary Caregiver Full Name

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* 7. Contact Phone Number

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* 8. Email address

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* 9. Work and School Status

Currently working

Looking for work

Attending classes (GED, College, Trade-School, ESL)

None

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* 10. How many hours per week work and/or attend classes

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* 11. Gross monthly income

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* 12. Other Income Sources

CalFresh (Food)

Welfare/Cash Aid

Social Security/Disability

None of these

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* 13. If yes to any of the above, how much?

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* 14. Other Caregiver Living in Home Full Name (if None skip to next page)

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* 15. Contact number

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* 16. Work and School Status

Currently working

Looking for work

Attending classes (GED, College, Trade-School, ESL)

None

Concord Child Care Center Eligibility List

Family Information

Question Title

* 1. Today's Date

Question Title

* 2. Are you applying for:

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* 3. What is your street address?

Question Title

* 4. Are you homeless or seeking permanent housing?

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* 5. Caregivers in Household (check all that apply)

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* 6. Primary Caregiver Full Name

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* 7. Contact Phone Number

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* 8. Email address

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* 9. Work and School Status

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* 10. How many hours per week work and/or attend classes

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* 11. Gross monthly income

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* 12. Other Income Sources

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* 13. If yes to any of the above, how much?

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* 14. Other Caregiver Living in Home Full Name (if None skip to next page)

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* 15. Contact number

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* 16. Work and School Status

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* 17. Hours per week working and/or attending classes

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* 18. Gross Monthly income