Preliminary Application

Please fill out all of the following information.

Parent's/Guardian's Name
Address
City
Zip
Home Phone
Email

Number of members in basic family
Child 1 Name	Birthdate	Day & Time of Care Needed
Child 2 Name	Birthdate	Day & Time of Care Needed
Child 3 Name	Birthdate	Day & Time of Care Needed

Parent's/Guardian's Employment	Mother	Father
Employer's Name
Address
Phone
Days & Hours

Parent's/Guardian's Presently in School	Mother	Father
Name of School
Current Enrollment Units
Vocational Goal
Days & Hours of Classes

Gross Income:
TANF	SSI/SSP	Income	Other
Wages	Pension	Workman's Comp	Alimony
Child Support Received	Child Support Paid Out	Other Income
Total Gross Income
Verification of the above will be needed at time of enrollment.


LIC# 150406460	LIC# 150406458	LIC# 150406459

Last updated 07/09/2009