Waiting List form

Birthdate of Child *

MM

DD

YYYY

Is this child currently enrolled in another preschool? *

Yes

No

Is this child a foster child?

Yes

No

Is this child bathroom independently?

Yes

No

In process

Does this child have an active CPS or at-risk referral from a licensed professional?

Yes

No

Does this child have an IEP (Individualized Education Plan)?

Yes

No

a) Is the child Hispanic or Latino? *

Yes, Hispanic or Latino

No, not Hispanic or Latino

b) What is the Race of your child? *

American Indian

Chinese

Japanese

Korean

Other Asian

Black or African American

White

Filipino

Hawaiian

Samoan

Other Pacific Islander

Cell Phone *

(###)

###

####

Home Phone

(###)

###

####

Please check all that apply

Working

Vocational Training Program

College/Education

Experiencing Homelessness

Seeking Employment

Stay at Home Parent

Incapacitation/Disability

Seeking Permanent Housing

If you receive any of the following (Please check all that apply)

Child Support: If yes, $______

Disability or Unemployment: If yes, $______

Spousal Support: If yes, $______

Cash Aid(CalWORKs or TANF): if yes, $______

Worker's compensation: If yes, $______

Housing Allowance: If yes, $______

Retirement or SSA: If yes, $______

Other Income: If yes, $______

Cell Phone

(###)

###

####

Home Phone

(###)

###

####

Please check all that apply:

Working

Vocational Training Program

College/Education

Experiencing Homelessness

Seeking Employment

Stay at Home Parent

Incapacitation/Disability

Seeking Permanent Housing

If you receive any of the following (Please check all that apply)

Child Support: If yes, $______

Disability or Unemployment: If yes, $______

Spousal Support: If yes, $______

Cash Aid(CalWORKs or TANF): If yes, $______

Worker's compensation: If yes, $______

Housing Allowances: If yes, $______

Retirement: If yes, $______

Other Income: If yes, $______

*

I certify the information provided above is accurate and true.

Today's Date *

MM

DD

YYYY

Acknowledgement *

By checking the boxes below and submitting this application, I acknowledge and understand the following:

Enrollment is conducted on a first-come, first-served basis according to the application date when vacancies become available. If I am contacted for an enrollment opportunity and choose to decline the space at the time, my position on the waitlist will remain unchanged.

Enrollment dates are determined when vacancies become available, and no specific dates can be guaranteed