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Concord Child Care Center Eligibility List
Family Information
*
1.
Today's Date
(Required.)
*
2.
Are you applying for:
(Required.)
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)
*
3.
What is your street address?
(Required.)
*
4.
Are you homeless or seeking permanent housing?
(Required.)
Yes
No
*
5.
Caregivers in Household (check all that apply)
(Required.)
Mother
Father
Legal Guardian
Step-Parent
Other (please specify)
*
6.
Primary Caregiver Full Name
(Required.)
*
7.
Contact Phone Number
(Required.)
*
8.
Email address
(Required.)
*
9.
Work and School Status
(Required.)
Currently working
Looking for work
Attending classes (GED, College, Trade-School, ESL)
None
*
10.
How many hours per week work and/or attend classes
(Required.)
*
11.
Gross monthly income
(Required.)
*
12.
Other Income Sources
(Required.)
CalFresh (Food)
Welfare/Cash Aid
Social Security/Disability
None of these
13.
If yes to any of the above, how much?
14.
Other Caregiver Living in Home Full Name (if None skip to next page)
15.
Contact number
16.
Work and School Status
Currently working
Looking for work
Attending classes (GED, College, Trade-School, ESL)
None
17.
Hours per week working and/or attending classes
18.
Gross Monthly income
Current Progress,
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