Eligibility List Online Application

  
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Primary Parent     Secondary Parent First Name * Last Name * Home Phone * Alternate Phone Date of Birth (mm/dd/yyyy) * Marital Status Please Select Single Married Divorced Separated Gender Please Select Male Female Address 1 * Address 2 City * Please Select Arnold Auburn Bear Valley Burson Cameron Park Camino Coloma Cool Diamond Springs El Dorado El Dorado Hills Fair Oaks Folsom Garden Valley Gardnerville Georgetown Granite Bay Greenwood Grizzly Flat Jackson Kelsey Kirkwood Kyburz Latrobe Livermore Lotus Markleeville Minden Mt. Aukum Omo Ranch Outingdale Pacific House Pilot Hill Placerville Pleasant Valley Pollock Pines Rancho Cordova Rescue River Pines Rocklin Roseville Sacramento Shingle Springs Somerset South Lake Tahoe Stateline Tahoma Woodfords Zephyr Cove State * Zip Code * Please Select 89449 95667 95682 95633 95614 95709 95613 95619 95623 95762 95634 95635 95636 95667 95720 95682 95651 95656 95675 95684 95684 95726 95672 95682 95684 89448 96150 96151 96152 96155 96156 96158 95684 95726 95746 89423 95225 95664 95670 95630 95223 95223 96120 89410 89460 96120 95642 95661 95677 95628 95604 County * Alameda Alpine Amador Butte Calaveras Colusa Contra Costa Del Norte El Dorado Fresno Glenn Humbolt Imperial Inyo Kern Kings Lake Lassen Los Angeles Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Orange Placer Plumas Riverside Sacramento San Benito San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Stanislaus Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba Email * An email address is required to complete this application. We will use this email to communicate with you in the future. Relationship to Child(ren) * Please Select Parent Grandparent Guardian Foster Parent Other Father Mother step parent Preferred Language * Please Select English Spanish Primary Language Please Select Arabic Armenian Assyrian Burmese Cantonese Cebuano (Visayan) Chalden Chamarro (Guamanian) Chaozhao (Chaochow) Croation Dutch English Farsi French German Greek Gujarati Hebrew Hindi Hmong Hungarian Ilocano Indonesian Italian Japanese Khmer (Cambodian) Khmu Korean Kurdish Lahu Lao Mandarin (Puntonghua) Marchallese Mien Mixteco Native American Languages Other Languages of China Other Languages of the Philipines Other non-English Pashto Pilipino (Taglog) Polish Portuguese Punjabi Rumanian Russian Samoan Serbian Serbo-Croation Spanish Taiwanese Thai Toishanese Tongan Turkish Ukrainian Urdu Ethnicity Please Select CAUCASIAN (NON-HISPANIC) AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN HISPANIC OR LATINO NATIVE HAWAIIAN OR PACIFIC ISLANDER UNKNOWN/DECLINE TO STATE Are you currently receiving cash aid or have you received cash aid in the last 24 months? * Yes No       Case Number * Reason for Needing Child Care * Actively Seeking Employment Education Or Training Incapacitated Protective Services Seeking Permanent Housing Working Part Day Educational Program CSPP No Need CSPP FRPM Residence   Primary Employer Zip Code Primary School Zip Code First Name Last Name Home Phone Alternate Phone Date of Birth (mm/dd/yyyy) Marital Status Please Select Single Married Divorced Separated Gender Please Select Male Female Ethnicity Please Select CAUCASIAN (NON-HISPANIC) AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICAN HISPANIC OR LATINO NATIVE HAWAIIAN OR PACIFIC ISLANDER UNKNOWN/DECLINE TO STATE Relationship to Child(ren) Please Select Parent Grandparent Guardian Foster Parent Other Father Mother step parent Preferred Language Please Select English Spanish Primary Language Please Select Arabic Armenian Assyrian Burmese Cantonese Cebuano (Visayan) Chalden Chamarro (Guamanian) Chaozhao (Chaochow) Croation Dutch English Farsi French German Greek Gujarati Hebrew Hindi Hmong Hungarian Ilocano Indonesian Italian Japanese Khmer (Cambodian) Khmu Korean Kurdish Lahu Lao Mandarin (Puntonghua) Marchallese Mien Mixteco Native American Languages Other Languages of China Other Languages of the Philipines Other non-English Pashto Pilipino (Taglog) Polish Portuguese Punjabi Rumanian Russian Samoan Serbian Serbo-Croation Spanish Taiwanese Thai Toishanese Tongan Turkish Ukrainian Urdu Email Are you currently receiving cash aid or have you received cash aid in the last 24 months? Yes No       Have you received CalWORKs Cash Aid in the last 24 months? Yes No       Reason for Needing Child Care * Actively Seeking Employment Education Or Training Incapacitated Protective Services Seeking Permanent Housing Working Part Day Educational Program CSPP No Need CSPP FRPM Residence   Secondary Employer Zip Code Secondary School Zip Code

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