Survey - A Special Place Preschool Wait List Application

A Special Place Preschool Wait List Application

*1.

Question - Required - Date:

Month

Day

Year

Question - Not Required - Guardian:

Question - Not Required - Mother:

Question - Not Required - Father:

*5.

Question - Required - Marital Status: Single
Separated
Divorced
Married
Foster Parent

Contact Information:


*	First Name: Required
*	Last Name: Required
	Email:
*	Street Address: Required
	Apt/Box/Unit/Suite:
*	City: Required
*	State / Province: Required
*	ZIP / Postal Code: Required
*	Phone Number: Required

*7.

Question - Required - Child's Name:

*8.

Question - Required - Age:

*9.

Question - Required - Birth date:

Month

Day

Year

A Special Place is a state subsidized full day preschool. Famlilies must meet the need and eligibility guidelines for enrollment. Please give us the following information to help us determine your eligibility.

*10.

Question - Required - Family Size:

*11.

Question - Required - Parents works 30 plus hours a week during the hours of 8-3. (Parent will provide work verification letter from employer of hours they work M-F)

*12.

Question - Required - Parent is attending school during the hours of 8-3 M-F (Parent will provide school schedule and grades)

*13.

Question - Required - Parent is incapacitated and will provide a doctor's note

*14.

Question - Required - Parent has an active CPS case and can bring in a letter of referral from case worker

*15.

Question - Required - Parent is in Cal Works

16.

Question - Not Required - Foster Parent (provide case aid invoice)

We also provide the Federal Food Program based on family need.

*17.

Question - Required - Gross Income (Parent will provide one month paycheck stubs):

18.

Question - Not Required - SNAP number:

All families need to show current immunization record and a birth certificate for all children in the family.

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