California State Preschool Program
Program Eligibility Form
Child's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Contact
*
First Name
Last Name
Does your child have another parent or legal guardian
*
Please Select
yes
no
Parent 2/Guardian 2 Contact
*
First Name
Last Name
Relationship to child
*
example@example.com
Gross Family Income
*
Family Size
*
Please list all languages spoken at home:
*
Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your child a dual language learner?
*
Yes
No
California State Preschool Program (CSPP)
Program Eligibility Requirement
Please check all that apply to your family or child
*
Our family is currently receiving public aid (TANF, CalWORKs, SSI, etc.)
Our family meets income eligibility guidelines
Our family is experiencing homelessness
Our child is a recipient of child protective services, or has been identified as abused, neglected, exploited, or at-risk
Our child has a disability with an active IFSP or IEP
Program Interest - Preferred Schedule
Full-Day
Half-Day
Preferred Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Location
Burlingame
Redwood City
Please verify that you are human
*
Family Need for Childcare:
*
Please Select
CPS at Risk
Working
Attending School
Parental Incapacity
Seeking Employment
Submit
Should be Empty: