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.

"*" indicates required fields

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
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.
I understand the following*

Stay up-to-date with our monthly newsletter!

Davis Street is busy with many upcoming events and benefits for our community all year round.

Please stay tuned and get our latest news, health and wellness updates, and more.
By submitting this form you are consenting to receive marketing emails from Davis Street Community Center, Inc., 3081 Teagarden Street, San Leandro, CA 94577. https://davisstreet.org . You can revoke your consent to receive emails at any time by using the unsubscribe link at the bottom of every email.