D
Date: CHILD DEVELOPMENT CENTER APPLICATION
Time:
To add your child’s name to the Eligibility List, complete this application and return it to the Bakersfield College Child
Development Center, Office #202, 1801 Panorama Drive, Bakersfield, CA 93305. Call the office at 395-4369 to update if you
have any changes (i.e. income, family size, address or phone number).
You will be contacted when an opening becomes available.
Mother/Guardian’s Name Living with child(ren)? Yes ___ No ___
Father/Guardian’s Name Living with child(ren)? Yes ___ No ___
Physical Address and Telephone Number of Parent(s)/Guardian(s) Living with child:
Street Number City State Zip Code
Home Phone ( ) Cell ( ) Other ( )
Family Size / Number of Immediate Family Members
List ALL Children in the Family Date of Birth
_____________________________________
_____________________________________
_____________________________________
_____________________________________
____________________________
____________________________
____________________________
____________________________
MOTHER’S INFORMATION
(if living with child)
Student ID #
Please check ( ) all that apply:
Working
Full Time___ Part Time___
Student
Full Time___ Part Time___
Homeless
Seeking Employment
Medically Incapacitated
EMPLOYMENT:
Employer’s Name
Address
Phone
Days and Hours
PRESENTLY IN SCHOOL:
Name of School
Vocational Goal
Anticipated Completion Date
GROSS MONTHLY INCOME:
Please fill in the dollar amount for all that apply:
Employment Income Hourly Rate $
Hours Per Week
If Salaried Position, Monthly Gross $
CalWorks/TANF
SSI
(Social Security Income)
State Disability
Spousal Support
Child Support Received
Child Support Paid Out
Pension
Workman’s Comp
Other Income
$
$
$
$
$
$
$
$
$
Special Need?
___________________________
___________________________
___________________________
___________________________
FATHER’S INFORMATION
(if living with child)
Student ID #
Please check ( ) all that apply:
Working
Full Time___ Part Time___
Student Full Time___ Part Time___
Homeless
Seeking Employment
Medically Incapacitated
EMPLOYMENT:
Employer’s Name
Address
Phone
Days and Hours
PRESENTLY IN SCHOOL:
Name of School
Vocational Goal
Anticipated Completion Date
GROSS MONTHLY INCOME:
Please fill in the dollar amount for all that apply:
Employment Income Hourly Rate $
Hours Per Week
If Salaried Position, Monthly Gross $
CalWorks/TANF $
SSI
(Social Security Income) $
State Disability $
Spousal Support $
Child Support Received $
Child Support Paid Out $
Pension $
Workman’s Comp $
Other Income $
Fill out and print your form. Bring or mail to our office.
04/09
