Concord Child Care Center Eligibility List Family Information Question Title * 1. Today's Date OK Question Title * 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) OK Question Title * 3. What is your street address? OK Question Title * 4. Are you homeless or seeking permanent housing? Yes No OK Question Title * 5. Caregivers in Household (check all that apply) Mother Father Legal Guardian Step-Parent Other (please specify) OK Question Title * 6. Primary Caregiver Full Name OK Question Title * 7. Contact Phone Number OK Question Title * 8. Email address OK Question Title * 9. Work and School Status Currently working Looking for work Attending classes (GED, College, Trade-School, ESL) None OK Question Title * 10. How many hours per week work and/or attend classes OK Question Title * 11. Gross monthly income OK Question Title * 12. Other Income Sources CalFresh (Food) Welfare/Cash Aid Social Security/Disability None of these OK Question Title * 13. If yes to any of the above, how much? OK Question Title * 14. Other Caregiver Living in Home Full Name (if None skip to next page) OK Question Title * 15. Contact number OK Question Title * 16. Work and School Status Currently working Looking for work Attending classes (GED, College, Trade-School, ESL) None OK Question Title * 17. Hours per week working and/or attending classes OK Question Title * 18. Gross Monthly income OK NEXT