Fillable CDC Student App (Merced College)

Fill Online, Printable, Fillable, Blank CDC Student App (Merced College) Form

Use Fill to complete blank online MERCED COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CDC Student App (Merced College)

On average this form takes 22 minutes to complete

The CDC Student App (Merced College) form is 2 pages long and contains:

  • 0 signatures
  • 18 check-boxes
  • 80 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Merced College

BROWSE MERCED COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CA Rev 0213
Merced College Child Development Center
3600 M Street, Merced CA 95348
(209) 384-6245 www.mccd.edu/services/child_dev
(Application’s are valid for one (1) year from date completed)
This is an application to be placed on the waiting/eligibility list for the
Merced College Child Development Center
This is a NEW application This is a REVISED application
My occupational/vocational goal at Merced College is
I am enrolled in # of units, Student Id #
PARENT INFORMATION: A parent = (biological parent, adoptive parent, stepparent, foster parent, caretaker relative,
legal guardian boyfriend, girlfriend, domestic partner)
Do any of the children listed above have special needs? Yes No If so, who?
Parent 1:
Name: First Last:
Address: City State Zip:
Home
Phone:
Cell
Phone:
Message
Employer Name: if applicable Phone
Address: City State Zip:
Wages $ TANF $ SSI $
Child
Support
$ Other $
Are You Currently a Student Yes No
Parent 2:
Name: First Last:
Address: City State Zip:
Home
Phone:
Cell
Phone:
Message
Employer Name: if applicable Phone
Address: City State Zip:
Wages $ TANF $ SSI $
Child
Support
$ Other $
Are You Currently a Student Yes No
Total Gross Monthly Household Income = $
CHILD/CHILDREN INFORMATION: (List all children to be placed on waiting list)
First Name Last Name Date of Birth Gender
Male Female
Male Female
Male Female
Male Female
Office Use Only
GMI: _________
Rank:_________
Family Size: ____
*This application is for
STUDENTS who may
qualify for subsidized
services based on gross
monthly income. If you
believe you do not
quality for subsidized
services please complete
a private pay application.
Do
any of the children listed above have an active IEP/IFSP?
Yes No If so, who?
List any other children/family members living in your household
First Name Last Name Date of Birth Gender
Male Female
Male Female
Male Female
Male Female
I have completed the application to the best of my knowledge. I will notify the Merced College Child Development
Center of any changes in my family situation that may affect my ranking (income, family size, # of units) within 30 days.
I understand my application is good for one year, and that I will be automatically deleted after that time. I understand
that I will be deleted if my phone number is disconnected.
Signature: Today’s Date:
• Applications are active for one year from date completed – If household income or size changes, please submit a
REVISED application
• The Merced College Child Development Center services children from the age of 6 months to 5 years old
• To qualify for our program, you must meet both need and eligibility criteria. You must be able to submit birth certificates
for all children under the age of 18, immunization records for children enrolled including current TB test results.
• Your total gross monthly income and family size will determine if your childcare fees will be subsidized or pay.
• If you are a two parent household – both parents must be involved in some activity (school, work etc.) to qualify for
funding (for subsidized care only).
• When we have an opening for enrollment, we will call the number listed on the application – if phone is disconnected,
your application will be automatically deleted.
• If you are not married, but live with someone (i.e., boyfriend, girlfriend, domestic partner, etc.) and benefit from that
income, then you must include that person on the application.
• Each enrollment is on a case by case basis. We give priority enrollment to the lowest income student first. You will be
placed on the waiting list according to your gross monthly income and family size. When we have an opening we will
contact you by phone, so please make sure your phone numbers stays current. Notify the Center to any changes in
your household income, family size or other information.
• We also enroll community members (non student) at full pay fees when spots are available.
Please call (209) 384-6245 for additional information.
CA 0914
SUBMIT
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CDC Student App (Merced College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document