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BEANSTALK ELIGIBILITY WAITING LIST FORM

A. ADULT INFORMATION (please fill out form completely: include      each Parent/Guardian living in the home)


Relationship
Relationship
               
1
2 Employed

 
Employer or School
Zip
S
M
T
W
Th
F
S
Wk/School Hrs
1  
2  



B. INCOME PER MONTH (Include all sources BEFORE TAXES AND
DEDUCTIONS):
Employment Salary/Wages  
1
 
2
   
Unemployment Benefits  
1
 
2
   
Foster Grant  
1
 
2
   
CalWorks / Cash Aid  
1
 
2
   
  Self Employment  
1
 
2
   
  Child / Spousal Support  
1
 
2
   
SSI / SSA  
1
 
2
   
 
1
 
2
   

C. CHILD INFORMATION (Please include all children in the home)

Child Name
Sex
DOB
  MM/DD/YY
Age
School
Grade
Care
Needed
Hrs
Needed

WERE ANY OF THE CHILDREN LISTED ABOVE ENROLLED AT BEANSTALK BEFORE?

 
When?

D. Please check or select the program you prefer or which program will best suit      your needs:

FAMILY CHILD CARE HOMES

OR

STATE PRESCHOOLS BELOW


STATE PRESCHOOL FOR 3 AND 4 YEAR OLDS 3 HOURS PER DAY

AM Session Preschools (3 Hrs)
PM Session Preschools (3 Hrs)




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