Waiting List Application
Pasadena City College Child Development Center
1324 East Green Street, Pasadena, CA 91106
(626) 585-3180 / 585-3183 FAX
Today's Date:
Enrollment is requested for:
Child Information:
Name: Birth Date: Age:
Sex: Male
Female
Does your child have any special needs/requirements?
(This information is required if you are applying for a grant)
Single Parent Family? Yes No
Number of Family Members:
(Gross amount – before taxes)
Monthly Gross Income:
Guardian Information:
Name: Relationship to child:
Address:
Telepone: (home) (work)
Zip Code:
City:
(cell.)
Pasadena City College Student:
Community Education Student:
Pasadena City College Employee:
Full-time Part-time
Dept. Ext:
Community Member:
Program Applying For:
Infant
(4-15 months)
M-F M-W-F T-Th
a.m. session (7:30 a.m. to 12:00 p.m.)
p.m. session (12:00 p.m. to 4:30 p.m.)
Toddler
(15-24 months)
M-F M-W-F T-Th
a.m. session (7:30 a.m. to 12:00 p.m.)
p.m. session (12:00 p.m. to 4:30 p.m.)
Older Toddler
(24-36 months)
M-F M-W-F T-Th
a.m. session (7:30 a.m. to 12:00 p.m.)
p.m. session (12:00 p.m. to 4:30 p.m.)
Preschool
(3-5 years old)
M-F M-W-F T-Th
p.m. session (12:00 p.m. to 4:30 p.m.)
a.m. session (7:30 a.m. to 12:00 p.m.)
State Preschool
(3-4 years old / income eligible)
M-F (required)
p.m. session (12:00 p.m. to 4:30 p.m.)
a.m. session (7:30 a.m. to 12:00 p.m.)
Early Primary Education Program
(5 years old by Dec. 2nd)
M-F (This program is offered only in the morning 7:30 a.m. to 12:00 p.m.)
After-School Enrichment Program
(Early Primary Education Program)
M-F M-W-F T-Th p.m. session (12:00 p.m. to 4:30 p.m.)
Evening Care
(for 3-5 year olds ONLY)
Mon. Tues. Wed. Thurs. 4:30 p.m. to 7:30 p.m.
(
Rank _______ )
# _______
