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Mt San Jacinto College Preschool and Child Development (Mt. San Jacinto Community College District)

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PY 2015-2016 Revised: 4/28/17
Mt San Jacinto College
Preschool and Child Development Lab Center
Documentation List
Thank you for your interest in our preschool and child care programs.
The following is a list of documentation required to determine family eligibility and placement.
Birth Certificates for ALL children in the home (used to determine family size)
Immunization Record for child being enrolled must include:
o 3 Polio 4 DTaP 3 Hepatitis B 1 MMR 1 Hib 1 Varicella
Verification of Income (must be current within 60 days and include one or more of the following)
o Pay Stubs
o Signed and complete tax return for previous year (with Schedule C if Self-Employed)
o CalWorks or Cash Aid Notice of Action or Passport
o Social Security
o Disability Benefits
o Unemployment Benefits (Award Letter) and stubs
o Verification of Child Support for ALL children in the home
o CalFresh Notice of Action
Two proofs of Residency (must be current within 30 days)
o Utility bills
o Mortgage Statement
o Rental Agreement
Physical Exam Form completed by the child’s physician (physical must have been performed
within the past 12 months of the child’s enrollment. It must also include HGB, Lead and TB test
results.) Health Insurance Card for child being enrolled
Additional documentation may be required.
Please be advised that income and residency expire after 30 days.
J:\CDEC FORMS\ENROLLMENT\Enrollment forms\FAMILY NEEDS ASSESSMENT.doc
Mt. San Jacinto College
Child Development and Education Lab Center
Family Needs Assessment
Parent/Guardian Name(s): ________________________________________________________________
Child’s Name: ___________________________________________________________ Birth date: _____
Child’s Name: ___________________________________________________________ Birth date: _____
Child’s Name: ___________________________________________________________ Birth date: _____
Please assist us in our efforts to meet the needs of your child/ren and family. If you have concerns about
your child/ren, please check any/all areas that apply:
Hearing Learning/Cognitive development
Vision Social development
Speech Physical development
Behavior/Emotional development
Other_____________________________
Are any of your children currently receiving services for areas checked above? Yes No
If “yes”, what agency/school district is providing the services? ___________________________________
Are these services meeting your needs? Yes No N/A
Is a language other than English spoken in the home? Yes No
If “yes” what language? __________________________________________________________________
With what language is your child/ren most comfortable? ________________________________________
Do you feel that your child/ren is happy, secure and developing in the childcare setting you are currently
using? Yes No
Please indicate in which of the following areas you would like some assistance:
Financial Assistance: Legal Assistance:
Child support Custody
Food stamps Divorce/Legal separation
Money management Legal guardianship
TANF Restraining order
Health Information: Parenting Information:
Immunizations Child growth and development
Medical/Dental screening Grandparent support groups
Family planning Parenting classes
Aids/HIV Support groups
Healthy Family Teen parents
Food/Nutrition Assistance: Community Awareness:
Food programs Gang prevention
Nutrition classes Neighborhood Watch
WIC Parks and recreation
J:\CDEC FORMS\ENROLLMENT\Enrollment forms\FAMILY NEEDS ASSESSMENT.doc
Education/Career Counseling: Family Counseling:
Career counseling Domestic violence
Dress for success Substance abuse
Financial assistance Support groups
GED/Adult education Stress management
Job placement training
Life skills
Transportation: Housing:
__________________________ Home repairs
Low income housing
Utility assistance (gas, electric, phone)
Other:
___________________________________________________________________________________
How may we provide assistance? Information Referrals Workshops
If you are interested in workshops, what days and hours are you available?
Monday _______AM/PM Tuesday _______AM/PM Wednesday _______AM/PM
Thursday _______AM/PM Friday _______AM/PM Saturday _______AM/PM
What are some things you and your family do for fun?__________________________________________
What are some goals that you may have for yourself?___________________________________________
Additional comments or special concerns: ____________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
To the best of my knowledge, I have responded completely and accurately to the statements above.
_________________________________________________ ______________________________
Parent/ Guardian Signature Date
♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦♦
FOR OFFICE USE ONLY
Additional Information:___________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________ ________________ ________________________________
Staff Signature Date Classroom Placement
Eligibility List Information
Mt. San Jacinto College
Child Development and Education Lab Center
1499 N. State Street
San Jacinto, CA 92583
(951) 487-3605
Continued on back
For Office Use Only
❑ Fall ❑ Spring ❑ Summer
Received on: _____________
Rank: ______
Date: ______________________
Name of Parent(s) / Guardian(s) in the home:
_____________________________________________ _____________________________________________
Mother’s Last Name First Name Father’s Last Name First Name
Mailing Address: ______________________________________________________________________________
Street Apt. # City Zip Code
________________________ ______________________ ________________________
Home Telephone Work Telephone Cell Telephone
Children (in need of care):
First / Last Name Male / Female Birth Date
1. ___________________________________ _____ ____________________
2. ___________________________________ _____ ____________________
3. ___________________________________ _____ ____________________
Other children in the home:
1. ___________________________________ _____ ____________________
2. ___________________________________ _____ ____________________
3. ___________________________________ _____ ____________________
Total number of persons in basic family unit (related by blood, marriage or adoption): _______________________
Care needed: ❑ Monday ❑ Tuesday ❑ Wednesday ❑ Thursday ❑ Friday
Hours needed: ___________ ___________ _____________ ___________ ___________
Financial Needs Assessment
In order to help us determine eligibility for financial assistance, please provide the following information:
Have you received cash aid (TANF/AFDC) within the past 24 months? ❑ Yes ❑ No
If yes, on what date did this aid end? _______________________________________________
Are you currently receiving cash aid for: yourself? ❑ Yes ❑ No your children? ❑ Yes ❑ No
Please check all applicable boxes below:
❑ Single-parent family: ❑ Working ❑ Looking for work ❑ In school
❑ Two-parent family:
❑ Mother: ❑ Working ❑ Looking for work ❑ In school
❑ Father: ❑ Working ❑ Looking for work ❑ In school
Estimated gross monthly income from ALL SOURCES including salary before taxes, child support, alimony,
TANF/AFDC, unemployment, etc.: $ _______________________________
Do you pay COURT ORDERED CHILD SUPPORT for any child/ren not living with you?
❑ Yes ❑ No If yes, amount $ ___________________
Who is currently caring for your child/ren? _________________________________________________________
Is this licensed childcare? ❑ Yes ❑ No
Are you transferring from other subsidized childcare? ❑ Yes ❑ No If yes, please specify _______________
_____________________________________________________________________________________________
Is this a Social Services Referral? ❑ Yes ❑ No If yes, please specify ______________________________
_____________________________________________________________________________________________
To enable the Child Development and Education Center to address the physical, cognitive,
emotional and social needs of your child/ren, please respond to the following statements as
completely as possible:
Does your child/ren have specific physical, cognitive, emotional and/or social needs? ❑ Yes ❑ No
If yes, please identify each child and describe his/her specific need/s: ___ __________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Has the need/s of your child/ren been professionally diagnosed? ❑ Yes ❑ No
If yes, please identify the resources that are currently helping to meet the need/s of your child/ren:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Additional comments or special concerns: _________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
To the best of my knowledge, I have responded completely and accurately to the above statements.
______________________________________ _______________
Parent / Guardian Signature Date
Please contact the center immediately
if there are changes in your address,
telephone, income, etc.
For Office Use Only
Reviewed by: ________
Date: _______________
REC: _______________
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Mt San Jacinto College Preschool and Child Development (Mt. San Jacinto Community College District)

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Completed 25 July 2020

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