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Parent/Guardian Name: |
Home Phone: |
Work Phone: |
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Parent/Guardian Name: |
Home Phone: |
Work Phone: |
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Street Address: |
zip: |
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Mailing Address: |
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zip: |
Preschool
Total Number of people in the family______
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Names & Birthdates of all children in family |
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Name |
Birthdate |
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Complete for all income sources that apply: |
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Gross Income from Wages |
$ |
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CalWORKS Income |
$ |
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Cash Aide Income |
$ |
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Child Support Income |
$ |
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Other Income |
$ |
Do you participate in the CalWORKS program? oYe s o No
Please attach income verification (copy of last year’s tax return or copy of one month’s pay stubs.)
This application places your child on the Eligibility List. You will be notified when your child is accepted.
I declare under the penalty of perjury that the above information is true and correct to the best of my knowledge.
______________________________________________ ___________________
Parent/Guardian Signature Date
For more information: www.mcoe.us (click on Departments)