| Email Address |
|
| DATE
OF WAITLIST TAKEN BY |
|
| MOTHER'S
NAME |
|
| SOCIAL
SECURITY # |
|
| ADDRESS: |
|
| ZIP: |
|
| PHONE: |
|
| FATHER'S
NAME |
|
| SOCIAL
SECURITY # |
|
| ADDRESS,ZIP,PHONE
|
|
| NAME/PHONE
# TO BE REACHED IF NO HOME PHONE |
|
| CHILD'S
NAME |
|
| DATE
OF BIRTH |
|
| NAME
OF SCHOOL |
|
| AGE
OF CHILD (FOR SAP ONLY) |
|
|
REASONS FOR
CHILD CARE
|
|
| MOM-NAME OF EMPLOYER/SCHOOL |
|
| HOURS @ WORK WORK |
|
| WORK PHONE # |
|
| GROSS PAY $ |
|
| DAD-NAME
OF EMPLOYER/SCHOOL |
|
| HOURS
@ WORK |
|
| PHONE
# |
|
| GROSS
PAY $ |
|
| INCOME
INFO AFDC AMOUNT $ |
|
| SOCIAL
SECURITY AMOUNT $ |
|
| ARE
YOU A VOUCHER ELIGIBLE? |
Yes
No
|
| DO
YOU HAVE TRANSPORTATION? |
Yes
No
|
| IS
THE CHILD IN ANOTHER DAY CARE? IF YES, WHERE? |
|
| REFERRED
BY |
|
| DAY
CARE IS NEEDED |
|
Comments:
|
|
|
