Preschool Online Application Form
Free or Low Cost for Income Eligible Families

To enroll into Head Start & State Preschool for children 3-5 years old, please fill out the following application.  A Child Development staff member will get back to you about next steps in registering your child for preschool.  

If you do not have computer access, applications can be picked up in the lobby of the Enrollment Center, located at 5601 47th Avenue, M-F 8:00am -1:00pm.

Please understand that filling out this form does not guarantee a spot for your child in our program. Additional documents will be needed to complete your child’s enrollment.

See information on preschool locations

Eligibility Information
Family Identification
Parent/Caretaker 1
Parent/Caretaker 2
Family Eligibility and Reason for Needing Service
Reason for Needing Service

Select yes if anyone in the household is applicable to the questions below. 

Employment/ Training Information

Must be completed for each adult listed above to document need on basis of employment or training.

Parent/Caregiver 1
Employer/School 1
Employer/School 2
Parent/Caregiver 2
Employer/School 1
Employer/School 2
Family Adjusted Gross Monthly Income and Size

The family’s adjusted monthly income for all sources. 

Non-Household Emergency Contacts

Authorized to pick up and care for the student with written or verbal permission.

Emergency Contact 1
Emergency Contact 2
Emergency Contact 3
Data on Children

List all children residing in the home and counted in the family size.

Children Residing in the Home
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8
Notice of Certification
For Single Parent/Caretakers ONLY

I understand that I am self-certifying single parent status under penalty of perjury in Family Identification section of this form when the single parent/caretaker box has been checked.

I understand that the information about my eligibility may be reviewed by representatives of the State of California, the federal government, independent auditors, or others as necessary for the administration of the program. 

I understand that if the agency denies this application for services, I have the right to appeal. 

I understand that I will receive a notice of approval or disapproval of my application within 30 days from the date I sign this form. 

I understand that this certification is not complete until all documentation is submitted and this form has been signed and dated by me and reviewed, signed, and dated by an agency representative. 

I certify that my family assets do not exceed $1,000,000; Child Care and Development Block Grant Act Section 658 p (4)(B). 

I understand that I must renew my eligibility at least once a year. I further understand that if I do not renew my eligibility, I will no longer be eligible for subsidized child care services for my child. 

Health and Development History
Student's Information
Health History

Leg/ankle braces, walker, wheelchair

Child squints, eyes crossed, “lazy eye”, etc.

Medication
Dental History
Special Concerns

Please provide us with the following important information that will help your child have a safe and smooth transition into the classroom. 

Health

Such as dairy-free, peanut-free, no pork, etc.

Special Needs

Such as ALTA, SCOE, CCS, NOR-CAL, Easter Seals, Shriner’s Hospital