Cross Cultural Family Center

P.O. Box 15366, San Francisco, CA, 94115

Telephone: (415) 921-7019

Fax: (415) 921-7132

E-mail: Gloria (Spanish/English) ggiron@crossculturalsf.org

Susan (Cantonese/Mandarin/English) susan@crossculturalsf.org

Young(Korean/English) ylee@crossculturalsf.org

Application for Child Care Services

Location

Entry Age

Center Preference #1

Center Preference #2

Application to enroll the following child(ren):

Child's Name (last name, first name)

Birthdate

Name and address of parent/guardian:

A) Name of Parent(s) or Guardian(s): (last name, first name)

B) Name of Parent(s) or Guardian(s): (last name, first name)

Home Address: (Street, City, Zip)

Cell Telephone

Work Telephone

E-mail Address

Employment &/or Training information of parent(s)/guardian(s):

A) Name of Employer/ School of Parent

B) Name of Employer/ School of Parent

Address (street, city, zip)

Telephone

FAMILY SIZE: (Includes parents, children, and other dependents living in this household)

GROSS MONTHLY INCOME (Pre-Tax): (include all sources of household income).

Eligibility and Need Information for State-Subsidized Child Care

Sources of Income (Check all that apply and include income of all household members):

Parent A

Parent B

Need for Child Care

Parent A

Parent B

Certification

I certify by my signature below, that all income that I/we receive has been listed above, and that if my application is selected for enrollment, I/we will be required to provide proof of income and need for child care services. I agree to notify Cross Cultural Family Center when any change occurs in my/our income or eligibility status. I understand that if my family receives subsidized child care services, information pertaining to my eligibility is subject to review by State of California representatives. I understand I have the right to appeal the denial of my request for child care services.

Parent A:

Parent B:

Signature

Date