Application for Services

All applicable questions on this application must be FULLY answered or this application cannot be processed.

Click here for CSPP eligibility requirements.

* Required

Today's Date*

MM slash DD slash YYYY

Programs and Sites

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Select one of these programs:*

California State Preschool Program (CSPP)

Tuition Based Program

Select all the sites you're interested in:*

Fairgrounds Early Education Center - 2667 E. Lake Ave. Watsonville, CA 95076

Vista Verde Early Education Center - 1936 Freedom Blvd., Freedom, CA 95019

Sycamore Street Early Education Center - 121 Sycamore St. #100, Santa Cruz, CA 95060

Nuevo Dia Early Education Center - 135 Leibrandt Ave., Santa Cruz, CA 95060

Redwood Mountain Early Education Center - 7103A Hwy 9, Felton, CA 95018

Highlands Park Early Education Center - 8500 Hwy 9, Ben Lomond, CA 95005

Child's Information

First Name*

Middle Initial

Last Name*

Birth Date*

MM slash DD slash YYYY

Does your child currently have an IEP or IFSP?*

Yes

No

Has a pediatrician recommended assessment for speech/language or any other developmental delay?*

Yes

No

Parent A's Information

First Name*

Middle Initial

Last Name*

Phone*

Email*

Address*

Number/Street City State Zip Code

Parent B's Information

First Name

Middle Initial

Last Name

Phone

Address

Number/Street City State Zip Code

Family Information

Family Size*

Number of family members living in the same home, related by blood or marriage.

Does Parent A live in home with child?*

Yes

No

Does Parent B live in home with child?

Yes

No

Children in the Family (Names and Birthdates)

Name

Birth Date

MM slash DD slash YYYY

Name

Birth Date

MM slash DD slash YYYY

Name

Birth Date

MM slash DD slash YYYY

Name

Birth Date

MM slash DD slash YYYY

Reason for needing early education services*

Employment

Looking for Job

School

Other

If Other, please explain below:*

How did you learn about us?*

Family

Friend

Internet

Flyer

Other

If Other, please explain below:*

Parent A's Work/School Information

Place of Employment/School Attending*

Phone*

Work/School Schedule *

Monday

Tuesday

Wednesday

Thursday

Friday

Gross Monthly Income for Parent A*

Are you a CalWORKs or Voucher participant?*

Yes

No

If so, your ID #*

Parent B's Work/School Information

Place of Employment/School Attending

Phone

Work/School Schedule

Monday

Tuesday

Wednesday

Thursday

Friday

Gross Monthly Income for Parent B

Are you a CalWORKs or Voucher participant?

Yes

No

If so, your ID #

I declare under penalty of perjury that the above information is true and correct to the best of my knowledge. I will notify the childcare center immediately if there is any change in my income, family size, residence, employment or reasons for needing child care services.

Parent Signature (type full name)*

Date*

MM slash DD slash YYYY

CAPTCHA

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Comments

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