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First Name (Required)

Last Name (Required)

Birthday (Required)

Email Address (Required)

Confirm Email Address

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Mobile Phone

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

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Hispanic or Latino

Middle Eastern or North African

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White

Prefer not to answer

Lives with Family (Required)

English Proficiency (Required)

Other Language

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Martial Status (Required)

Has Income (Required)

Other Income?

Employer 1 Name

Employer 1 Phone Number

Employer 2 Name

Employer 2 Phone Number

Gross Annual Income (Required)

In School or Training? (Required)

School Name

School Units

School Phone Number

Is your family experiencing homelessness?

Living Address (Required)

Address Line 2

City (Required)

State (Required)

ZIP (Required)

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Please complete this section if Secondary Parent is related by Blood, Marriage, Adoption or Foster.

Is there another parent/guardian in the family?

First Name (Required)

Last Name (Required)

Birthday (Required)

Gender (Required)

Email Address

Confirm Email Address

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Mobile Phone

Home Phone

Work Phone

Ext.

It appears that you have previously submitted an application. If you wish to apply again, please contact us by phone or in person.

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Lives with Family (Required)

English Proficiency

Other Language (Required)

Highest Grade Completed (Required)

Employment Status (Required)

Child's Relationship (Required)

Custody (Required)

Provides Financial Support (Required)

Martial Status (Required)

On parent's income? (Required)

Has Income (Required)

Other Income?

Employer 1 Name

Employer 1 Phone Number

Employer 2 Name

Employer 2 Phone Number

Gross Annual Income

In School or Training?

School Name

School Units

School Phone Number

Are there other adults in the household?

Add Another Adult

If you receive any government aid such as TANF, Cash Aid, or SSI you are eligible for our services.

Number in Family (Required)

Is your family receiving cash benefits or other services under the Temporary Assistance for Needy Families (TANF) program? (Required)

Is your family receiving Supplemental Security Income (SSI)? (Required)

Is your family receiving services under the Supplemental Nutrition Assistance Program (SNAP), formerly referred to as Food Stamps? (Required)

Add Emergency Contact

First Name (Required)

Middle Name

Last Name (Required)

Birthday (Required)

Gender (Required)

Race and/or Ethnicity - To specify multiracial and/or multiethnic please check all races and/or ethnicities that apply (Required)

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Birth Country (Required)

Language at Home (Required)

Language at Home Other

Language Used Most (Required)

Language Used Most Other

Language Request from ELS

Child in Foster Care

Current IEP/IFSP

Parents/Guardians at Home (Required)

Language Exposed at Home

Language Exposed Other

Language Exposed at Comm.

Language Exposed Com. Oth

Language Understand

Language Understand Other

Language Use to Comm.

Language Use to Com Other

Which program are you applying for? (Required)

Location Preference

1st Location Preference

2nd Location Preference

3rd Location Preference

- Your Address - Available Locations

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Do you want to apply now for another child in your family?

Add Another Applicant

Are there other children in the family?

Add a Sibling

Parent/Guardian

Address

Additional Parent/Guardian

Other Adults

Family Information

Emergency Contacts

Child (Applicant)

Location Preferences

Additional Applicant

Siblings