1
Antelope Valley College Child Development Center
California State Preschool Preliminary Application
Contact Information
Parent or Guardian #1 Name: Full Name ______________________________ Home Phone _______________ Email _____________________________
Address ________________________ City __________________ Zip Code _________ Primary Language ____________ Ethnicity __________________
Employer/School Name _________________________________________________ Work/School ZIP ___________ Work/Cell Phone __________________
Parent or Guardian #2 Name: Full Name ______________________________________ Primary Language _____________ Ethnicity __________________
Employer/School _______________________________________ Zip Code __________________ Work/Cell Phone _________________________________
Single Parent Family ______ 2 Parent Family _________
Need for Child Care: (please check all that apply for each parent/guardian)
Parent/Guardian #1 _____Working _____ Incapacitated/Disabled _____Seeking Work ____Homeless ____ In School/Traini
ng _____ Migrant Worker
Parent/Guardian #2
____Working _____ Incapacitated/Disabled _____Seeking Work ____Homeless ____ In School/Training _____ Migrant Worker
Family Income: Income Sources (Total dollars from all sources before taxes and deductions. Write in dollar amount per month for each source)
Parent/Guardian #1 Parent /Guardian #2
Work/Employment $__________ $__________
Child Support $__________ $__________
Spousal Support $__________ $__________
State/Private Disability $__________ $__________
Unemployment benefits $__________ $__________
Sales/Work Commissions $__________ $__________
Cash Aid
$__________ $__________
Worker’s Compensation
$__________ $__________
Other (explain) $__________
$__________
$__________ total monthly $__________ total monthly
CalWORKS / CASH AID
Are you currently receiving cash aid?
YES____ NO ____
NOTE: Information provided on this form will be used to
establish initial eligibility for State Preschool.
Applicants must fill in ALL AREAS on page 1 and 2
of this form to determine eligibility. Full
documentation will be required prior to enrollment
in a program.
Incomplete applications may not be entered.
2
CHILD INFORMATION (The purpose of this form is to collect information required to establish eligibility of the child/family.)
Name of Child Applying for Preschool: #1 _________________ Birth Date: ________ Gender: M __ F __ Foster Child? ___ $ _______ monthly
Primary Language: _________________ Ethnicity: ____________________
SIBLINGS / OTHER CHILDREN (UNDER AGE 18) LIVING IN HOME
First and Last
Name Birth date Gender Foster Child Child Needs Care?
(check if “yes”)
#2. _____________________________ ___ / ___ / ____ M __ F __
#3. _____________________________ ___ / ___ / ____ M __ F __
#4. _____________________________ ___ / ___ / ____ M __ F __
Special Needs
Child #1
Child #2
Child #3
Limited English
Child Protective Services
Severely handicapped
Does child have an IEP, IFSP
Receive services through
Regional Center or School District
Social / Emotional / Behavior
Ongoing health problems
Developmental delays?
Vision/Hearing
Other
Required: Is your child currently enrolled in Head Start or another
State Preschool?
___ No ___ Yes Child # _____ Name of School: ________________________
Is your child enrolled in any other subsidized program?
___ No ___ Yes Child # ______ Program _____________________________
SIGNATURE REQUIRED
I Swear under penalty of perjury that the above information is true and correct, and that I have included all sources of income. I hereby authorize agency staff to
verify wages with my employer. In addition, I authorize the release and sharing of my files by legally authorized personnel from the agency, from California
Department of Education, or from Community Care Licensing to determine program compliance, family eligibility, and conformance with regulations and reporting
requirements. I understand that this is a preliminary application ONLY and does not guarantee enrollment in the program.
_______________________ ________________________________________________
________________________________________________
Signature of Parent (or type your full name)
Date Relationship to Applicant Child
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome