Early Learning Eligibility Form

Date

Primary parent(Required)

First Last

Primary parent date of birth(Required)

Please indicate which type of care you need:(Required)

Full-time

Part-time (9 am - 12 noon)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Secondary parent

First Last

Are you a single-parent family?(Required)

Yes

Family size(Required)

Child 1 full name(Required)

First Last

Birthdate(Required)

Child 2 full name

First Last

Birthdate

Child 3 full name

First Last

Birthdate

Child 4 full name

First Last

Birthdate

Child 5 full name

First Last

Birthdate

Primary parent is:(Required)

Secondary parent is:

Household's gross monthly income (before taxes)(Required)

Income source (Check all that apply)(Required)

Please check the center(s) you prefer:(Required)

Early Learning Center, San Mateo (2 months to 5 years)

First Step CDC, San Mateo (18 months to 5 years)

Haven CDC, Menlo Park (18 months to 5 years)

Leo J. Ryan CDC, South San Francisco (3 to 5 years)

Club Leo J. Ryan, South San Francisco (5 to 12 years)

Mission CDC, Daly City (2 months to 3 years)

87th Street CDC, Daly City (3 to 5 years)

Midway CDC, Daly City (2 months to 5 years)

Our Second Home CDC, Daly City (3 to 5 years)

Are you interested in other services?

Mental Health Services

Transportation

Older Adult Services

How did you hear about us?(Required)

Early Learning Eligibility Information Form

Fill out the Form

Early Learning Eligibility Information Form