Pre-Eligibility Form | Girls Club of Los Angeles / Faith Children's Center

GIRLS CLUB OF LOS ANGELES

2057 W. Century Blvd., Los Angeles, CA 90047 • Tel: (323) 754-2122 • Fax: (323) 754-4353
GCLA serves families throughout South Los Angeles, the South Bay region, Long Beach, and select areas of Greater Los Angeles. Eligibility will be reviewed based on the ZIP code provided.
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PRE-ELIGIBILITY REGISTRATION FORM

Thank you for your interest in our Girls Club of Los Angeles Early Education Program. The first step is to complete the Pre-Eligibility Form. After we receive your form, our team will review your information, verify eligibility requirements, and contact you with the next steps for enrollment and services. If you have any questions, you are welcome to contact our Intake Department - 323 - 754 - 2122 • intake@girlsclubla.org
Parent/Guardian 1 Name

First NameLast Name
What Girls Club of Los Angeles Program are you interested in?
When would you like your child to begin care?

ENDPART I- CHILD INFORMATION (For child(ren) you are applying for childcare services)

Rows	Child's Name (first, middle, last)	Gender (Male)	Gender (Female)	Date of Birth	Full-time	Part-time	Evenings/ Weekends
1
2
3
4

Special Needs (Check all that apply for child(ren) you are applying for childcare services)

Rows	Child 1	Child 2	Child 3	Child 4
Child Protective Services
Child has IFSP (Individual Family Service Plan) or IEP (Individual Education Plan)
Child receives services through Regional Center or the local School District
Social emotional / behavior
Ongoing health problems
Developmental delays
Speech/communication
Vision or hearing
Other (please explain):

PART III - CHECK OFF NEED FOR CHILD CARE

Rows	Parent/Guardian 1	Parent/Guardian 2
In School/Training (School Verification)
Working (Employment Verification, Declaration of Self-Employment)
Medically Incapacitated/Disabled (Incapacity Verification Form)
Looking for work (Provide Weekly Logs)
Homeless/Seeking Housing (Letter from Shelter, County)
Migrant Worker (Declaration of Self-Employment)
Part Day Educational Preschool Experience for Child

Rows	Parent/Guardian 1 \| Enter the Monthly Income	Optional: Parent/Guardian 2 \| Enter the Monthly Income
Employment
Child Support
Spousal Support
State Disability
Unemployment
Sales/Work Comp
Cash Aid
Workmen's Comp
Other
TOTAL

GIRLS CLUB OF LOS ANGELES