Calpella ElementaryUkiah Unified School District

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Forms » Preschool Application

Preschool Application


For office use only                   Circle one:


Date received: _________    3      4      Rank#_____


Calpella State Preschool

151 Moore Street

Ukiah, CA 95482


Application for Services





Parent/Guardian Name:

Home Phone:

Work Phone:

Parent/Guardian Name:

Home Phone:

Work Phone:

Street Address:


Mailing Address:





Child’s Name_________________________________  Birth Date_______________

Total Number of people in the family______

Names & Birthdates of all children in family
















Complete for all income sources that apply:

Gross Income from Wages


CalWORKS Income


Cash Aide Income


Child Support Income


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


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