WAITLIST INFORMATION
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
PHONE #
GROSS PAY $
DAD-NAME OF EMPLOYER/SCHOOL
HOURS @ WORK WORK
PHONE #
GROSS PAY $
INCOME INFO AFDC AMOUNT $
SOCIAL SECURITY AMOUNT $
ARE YOU A VOUCHER ELIGIBLE?
Yes
No
DO YOU HAVE TRANSPORTARTION?
Yes
No
IS THE CHILD IN ANOTHER DAY CARE? IF YES, WHERE?
REFERRED BY DATE CARE IS NEEDED
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