IVC Preschool & Infant Toddler Center

Waiting Pool Application

Basic Child Information:
Name of child you are requesting services for:
Child's Age
Child's Date of Birth Child's Date of Birth / MM / DD YYYY
Family Size
Parent Information:
Check if you are a single parent

Check if you are a single parent Single Parent
Parent A: Name
Parent A: G#
Parent A: Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Phone Home Phone - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Work Phone Work Phone - ### - ### ####
Parent B: Name
Parent B: G#
List all children under the age of 18 living in the household:

Please list name and of birth date
Child #1 Child #1 First Last
Child #1 Date of Birth Child #1 Date of Birth / MM / DD YYYY
Add Child #2?

Add Child #2? Yes
Child #2 Child #2 First Last
Child #2 Date of Birth Child #2 Date of Birth / MM / DD YYYY
Add Child #3?

Add Child #3? Yes
Child #3 Child #3 First Last
Child #3 Date of Birth Child #3 Date of Birth / MM / DD YYYY
Add Child #4?

Add Child #4? Yes
Child #4 Child #4 First Last
Child #4 Date of Birth Child #4 Date of Birth / MM / DD YYYY
Add Child #5?

Add Child #5? Yes
Child #5 Child #5 First Last
Child #5 Date of Birth Child #5 Date of Birth / MM / DD YYYY
NEED STATUS
Gross monthly income $ Dollars . Cents
Gross weekly income $ Dollars . Cents
Bi-weekly income $ Dollars . Cents
What semester do you need care?
Parent A: # of Units
Parent A: Days Services Would be Needed for Work/School:

Parent A: Days Services Would be Needed for Work/School: Monday Tuesday Wednesday Thursday Friday
Parent A: Schedule Details (Hours Needed):
Parent B: # of Units
Parent B: Days Services Would be Needed for Work/School:

Parent B: Days Services Would be Needed for Work/School: Monday Tuesday Wednesday Thursday Friday
Parent B: Schedule Details (Hours Needed):
Documentation You Will Need to Bring if Contacted

California Department of Education requires documentation to verify family and income status as well as school/training and work status of parents and guardians for families applying for subsidized childcare and development programs. Documents must be provided for each parent/guardian living in the home.

- Income (Total countable income for all individuals counted in the family size)
- Gross wages including: commissions, overtime, tips, bonuses, gambling or lottery winnings
- Recent pay stubs (1 month worth no older than 30 days)
- Public Assistance (Passport to Services)
- Income tax
- Other proof of income
- Documentation of Unemployment
- Documentation of Employment
- Child Support documents
- Training/School Schedule
- Documentation of parent incapacity
- Documentation of family size
| - - Birth certificates, court records, adoption documents, foster care placement
| - - School or medical records, county welfare department records
- Child’s Immunization Record
- Child’s Physical

IVC Preschool & Infant Toddler Center

IVC Preschool & Infant Toddler Center

Basic Child Information:

Parent Information:

List all children under the age of 18 living in the household:

NEED STATUS

Documentation You Will Need to Bring if Contacted