Childcare Waitlist Enrollment Form

Which program are you interested in?(Required)

Parent/Guardian Information #1

What is your home language?(Required)

Address
Which describes your household?:(Required)

Reasons for Needing Childcare:

Check all that apply.
Parent/Guardian #1:(Required)

CalWORKs Participation (Cash Aid)

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
 
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
 
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.

Children Living in the Home

List all children under 18 who are members of the family.
Select date MM slash DD slash YYYY
Check all that applies to Child #1: