2020 Eligibility Application
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DEL NORTE SCHOOLS PRESCHOOL PROGRAMS ELIGIBILITY APPLICATION
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By placing your name on the eligibility list, you may be considered for enrollment if your family's gross monthly income is less than 70% of the State Median Income and space is available.
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APPLICANT INFORMATION
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Parent A or Guardian
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LastFirst
Middle Initial
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Home Address/Mailing Address
CityState
Zip
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Home Phone
Cell/Message Phone
Email Address
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Are you the parent, grandparent or guardian to the child?
YesNo
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Are you married and currently living with your spouse?
YesNo
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Is the second parent to at least one of the children living in the home?
YesNo
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SECOND PARENT INFORMATION (Only if currently living in the home)
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Parent B or Guardian
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LastFirstMiddle Initial
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Cell/Message Phone
Email Address
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REFERRAL INFORMATION
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Is the family homeless? (couch surfing or staying at a motel)
YesNo
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Were you referred by Child Protective Services?
YesNo
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(A CPS Social Worker may refer children who are receiving CPS services as part of a CPS case plan.)
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INCOME INFORMATION
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Enter your gross monthly income from all sources.
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Regular Monthly Income
Parent AParent BOther Family Income
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Employment/Self Employment
$ $ Cash Aid (children only/foster) $
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SSA (parent)
$ $ Cash Aid (family) $
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SSI/SSP (parent)
$ $ Child Support Received $
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Spousal Support Received
$ $ Spousal Support Received $
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Unemployment
$ $ SSA (child) $
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Other $ $ Other $
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Income Adjustments: Child Support Paid -
$ (Deduct from monthly income)
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FAMILY'S GROSS MONTHLY INCOME (gross income is before taxes)$
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CHILDREN TO BE ENROLLED
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Name
Date of Birth
Special Needs (IEP)
Primary Language
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LIST ALL OTHER CHILDREN IN THE FAMILY
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Name
Date of Birth
Name
Date of Birth
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FAMILY SIZE (Total # of people supported by this income)
# in Family
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I declare that the above information is true and complete to the best of my knowledge.
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Parent/Guardian Signature
Date
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Mail your completed form to:
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DNCUSD State Preschool, 301 W. Washington Blvd., Crescent City, CA 95531 Site/Class Requested:
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Questions: 707.464.0720 or 707.464.6141Office Use Only Rank: List:__________ Entered:____________
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