2024 Eligibility Application

	B	D	E	F	G	H	I	J	K	L	N	O	P	Q
1	DEL NORTE SCHOOLS PRESCHOOL PROGRAMS ELIGIBILITY APPLICATION
2	By placing your name on the eligibility list, you may be considered for enrollment if your family's gross monthly income is less than 85% of the State Median Income and space is available.
3	APPLICANT INFORMATION												Office Use Only: Appt: Contacted: Dropped:	Pulled Packet:
4	Parent A or Guardian
5		Last					First				Middle Initial
6
7	Home Address/Mailing Address					City				State	Zip
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9	Home Phone		Cell/Message Phone						Email Address
10	Are you the parent, grandparent or guardian to the child?							Yes		No
11	Are you married and currently living with your spouse?							Yes		No
12	Is the second parent to at least one of the children living in the home?									Yes	No
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14	SECOND PARENT INFORMATION (Only if currently living in the home)
15	Parent B or Guardian
16		Last						First			Middle Initial
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18	Cell/Message Phone						Email Address
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20	REFERRAL INFORMATION
21	Is the family homeless? (couch surfing or staying at a motel)							Yes		No
22	Were you referred by Child Protective Services?							Yes		No
23	(A CPS Social Worker may refer children who are receiving CPS services as part of a CPS case plan.)
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25	INCOME INFORMATION
26	Enter your gross monthly income from all sources.
27	Regular Monthly Income		Parent A		Parent B			Other Family Income
28	Employment/Self Employment		$		$			Cash Aid (children only/foster)			$
29	SSA (parent)		$		$			Cash Aid (family)			$
30	SSI/SSP (parent)		$		$			Child Support Received			$
31	Spousal Support Received		$		$			Spousal Support Received			$
32	Unemployment		$		$			SSA (child)			$
33	Other		$		$			Other			$
34	Income Adjustments: Child Support Paid -				$		(Deduct from monthly income)
35	FAMILY'S GROSS MONTHLY INCOME (gross income is before taxes)								$
36
37	CHILD TO BE ENROLLED
38	Name			Date of Birth			Special Needs (IEP)		Potty Trained	Primary Language
39							Yes		Yes
40							No		No
41							Speech Only		Partly
42	LIST ALL OTHER CHILDREN IN THE FAMILY
43	Name			Date of Birth			Name			Date of Birth
44
45
46
47	FAMILY SIZE (Total # of people supported by this income)								# in Family
48	I declare that the above information is true and complete to the best of my knowledge.
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50	Parent/Guardian Signature				Date				Office Use Only:
51												SPEL
52	Mail your completed form to:											Sibling
53	DNCUSD State Preschool, 301 W. Washington Blvd., Crescent City, CA 95531
54	Questions: 707.464.0720 or 707.464.6141								Rank: _____ GRID: _____ Zip:_______
55	Site/Class Requested: ________________								Month(s)/Day(s) =
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