Survey - YWCA Childcare Center Application

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YWCA Childcare Center Application

*1.

Question - Required - Date:

Month

Day

Year

*2.

Question - Required - From the list below, please select which schools you would like to apply to:
Please make between 1 and 2 selections from the choices below.

	Santa Rosa Preschool
	Petaluma/Two Rock Preschool
	Sebastopol Preschool
	Forestville Preschool
	Guerneville Preschool
	Monte Rio Infant / Preschool

3.

Question - Not Required - Guardian:

4.

Question - Not Required - Mother:

5.

Question - Not Required - Father:

*6.

Question - Required - Marital Status:

Single

Separated

Divorced

Married

Foster Parent

7.

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

*8.

Question - Required - Child's Name:

*9.

Question - Required - Age:

*10.

Question - Required - Birth date:

Month

Day

Year

If you are interested in qualifying for state funding, please fill out questions 11-18.
Famlilies must meet the need and eligibility guidelines for enrollment. Please give us the following information to help us determine your eligibility.

11.

Question - Not Required - Family Size:

12.

Question - Not Required - Does your child have an active IEP?

13.

Question - Not Required - Parents works 30 plus hours a week during the hours of preschool operation. (Parent will provide work verification letter from employer of hours they work M-F)

14.

Question - Not Required - Parent is attending school during the hours of preschool operation (Parent will provide school schedule and grades)

15.

Question - Not Required - Parent is incapacitated and will provide a doctor's note

16.

Question - Not Required - Parent has an active CPS case and can bring in a letter of referral from case worker

17.

Question - Not Required - Parent is in Cal Works

18.

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

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

19.

Question - Not Required - Gross Income (Parent will provide one month paycheck stubs):

20.

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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811 3rd St, Santa Rosa, CA 95404 | Phone: (707) 546-9922 | Fax: (707) 546-9928 | ywweb@ywcasc.org

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