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LOS ANGELES COMMUNITY COLLEGE DISTRICT LOS ANGELES SOUTHWEST (Los Angeles Southwest College)

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C:\Users\greyj\Desktop\new CDC application 2020-2021.doc
LOS ANGELES COMMUNITY COLLEGE DISTRICT
LOS ANGELES SOUTHWEST COLLEGE
CHILD DEVELOPMENT CENTER
(323) 241-5000
o You will be required to submit the following verifications of family income that
apply to you:
• TANF/CalWORKs Verification (Notice of Action) or
• Latest pay check stubs (1 month total household income) or
• Unemployment and/or Disability Verification
o You will be required to submit the following forms along with this application:
• Birth certificate of all children in the household under 18 years of age
• Immunization record and TB test results of the child(ren) that you are
applying for
• Current class printout, Educational Plan and most resent final grades.
Once your income has been verified:
Your application will be placed on the wait list
Your child care will be free or subjected to a flat monthly fee
You will be contacted to schedule an appointment when a space
becomes availabe to complete the enrollment process.
This application does not imply that your child has been accepted into
the center
You will be required to attend a program orientation date & time TBA.
Programs Offered:
Full Day Program: Monday – Thursday 7:30 am – 3:00 pm
Friday 7:30 am – 12:00 pm
Toddler
12 Months -36 Months
Pre-School
3 – 5 years of age (potty trained)
(Must be 3 years of age before September 1)
2020 – 2021 Enrollment Application
When submitting an application the following documents must be
attached and emailed to lasc-cdc@lasc.edu to be considered
complete:
C:\Users\greyj\Desktop\new CDC application 2019-2020.doc
LOS ANG
ELES COMMUNITY COLLEGE DISTRICT
LOS ANGELES SOUTHWEST COLLEGE
CHILD DEVELOPMENT CENTER
(323) 241-5000
APPLICATION FOR ENROLLMENT
PROOF OF YOUR CURRENT INCOME IS REQUIRED WITH THIS APPLICATION
THIS APPLICATION IS VALID FROM JULY 2020 – JUNE 2021
This application does not imply that your child has been accepted into the center.
You will be contacted regarding acceptance and parent orientation dates.
This application with required documents must be submitted via email to lasc-cdc@lasc.edu.
We are currently not accepting in person applications.
Are you a New Parent? Returning Parent?
PART I. – FAMILY INFORMATION
Name of all children in the family living in the household
1. _____________________________________
_______ _____________________ _____________
Child’s Name: Last, First, Middle Birthdate Age
(year/months)
2. ____________________________________________ _____________________ _____________
Child’s Name: Last, First, Middle Birthdate Age
(year/months)
3. ____________________________________________ _____________________ _____________
Child’s Name: Last, First, Middle Birthdate Age
(year/months)
4. ____________________________________________ _____________________ _____________
Child’s Name: Last, First, Middle Birthdate Age
(year/months)
Parent(s) residing in the home:
1. ____________________________________________ _____________________ __________________
Name: Last, First, Middle Home Phone # Message Phone #
2. ____________________________________________ _____________________ __________________
Name: Last, First, Middle Home Phone # Message Phone #
________________________________________________ ___________________ _______________
Home Address City Zip Code
________________________________________________________________________________________
E-mail Address
PART II – PROGRAM –
I understand that this is a year round full day program (fall, winter, spring) ________ (initials)
MON.
TUES.
WED.
THURS.
FRI
FULL DAY PROGRAM
7:30 am – 3:00 pm Monday – Thursday
7:30 am – 12:00 pm Friday
FOR OFFICE USE ONLY
DATE APP. RECEIVED ______
Toddler ______
Pre-School ______
Protective Services ______
Income ______
Family Size ______
Pay Utilities ______
Potty Trained ______
Fee ______
Age at Enrollment ______
Not Interested ______
No Show ______
No Income Provided ______
Called on ______
Appointment Date 1 _______
Appointment Date 2 _______
Appointment Date 3 _______
Notes:
_________________________
_________________________
_________________________
_________________________
PART III – FOR CalWORKs PARTICIPANTS ONLY
Are you a LASC CalWORKs Participant? Yes No
If so, you will need to complete the campus CALWORKs Verification Form prior to the beginning of
the semester.
PART IV – STUDENT STATUS
If you are applying as a “student only” (status), you must have a minimum of 9 units to be eligible for
child care.
(Must submit a class schedule once you are fully enrolled)
1. Are you a student? Yes No
2. Student ID #_______________________________________________________
3. Check the number of units you anticipate taking this semester:
12 units or more________ 9 units or more________ ESL ________
4. If you are married, and your spouse is currently enrolled, check the number of units your
spouse anticipates taking:
12 units or more________ 9 units or more________ ESL ________
5. Please check if you participate in the programs listed below:
EOP&S CalWORKs
Associated
Student Organization
Disabled
Student
Passage
Program
TRIO Program
Veteran’s
Program
Other
PART V – SOURCE OF FAMILY INCOME
Are you a single-parent family? Yes No
Total Number of Family Members_______________
Gross Monthly Income $ _______________________
What is the source of this income (Earned wages, TANF (AFDC), Soc, Sec., Etc.)?_____________________
PART VII
Name of Parent/Guardian Enrolling the child: __________________________ Relationship: ______________
PART VIII –CERTIFICATION
I declare under the penalty of perjury, that the information and documentation I have
provided, is true and correct to the best of my knowledge. I give the LACCD College Child
Development Center authorization to verify all information provided.
________________________________________________________ ________________________________
Signature Date
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2019-2020.doc
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LOS ANGELES COMMUNITY COLLEGE DISTRICT LOS ANGELES SOUTHWEST (Los Angeles Southwest College)

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Completed 25 July 2020

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