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

Early Learning Eligibility Information Form

Fill out the Form

Early Learning Eligibility Information Form