Eligibility List Application

This is an application for subsidized child care. By completing this application does not guarantee you will receive services. In order to remain active on the list, you must take immediate action to inform Davis Street of any changes to your address, phone number or income. This application is valid for six (6) months. You must contact Davis Street every six (6) months to request to remain on the list or your name will be removed.

Parent/Guardian #1

Name*
Marital Status (check one):*
Address*
Housing (check all that apply):

Parent/Guardian #2

Name

Reason (Need) for Care

Adult #1*
Adult #2
Employment salary or wages/self-employment income (before taxes) Child and/or spousal support received Social Security/Disability/ Workman’s Comp Unemployment Cash Aid/Welfare Other income Total Please describe other income Actions
               
There are no Adults.

Maximum number of adults reached.

As a parent, have you received Cash Aid (TANF) or have received a lump sum diversion payment within the last 24 months in California?*

Children

The following information should be completed regarding only those children living in the home for which you have legal responsibility.
Name Date of birth Gender Does the child have special needs? What type of care will this child need? If yes, does child have IEP/IFSP? Is there an open CPS case for your family? Is this a foster child? Actions
               
There are no Children.

Maximum number of children reached.

I understand the following*

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