Early Learning Eligibility Form

Date

Child's Name(Required)

First Last

Child's Date of Birth(Required)

Please indicate which type of care you need:(Required)

Full-time

Part-time (9 am - 12 noon)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Parent A Name(Required)

First Last

Parent B Name(Required)

First Last

Are you a single-parent family?(Required)

Yes

Family Size(Required)

Full name(Required)

First Last

Birthdate(Required)

Full name(Required)

First Last

Birthdate(Required)

Full name

First Last

Birthdate

Full name

First Last

Birthdate

Full name

First Last

Birthdate

Parent A is:(Required)

Parent B is:(Required)

Household's Gross Monthly Income (before taxes)(Required)

Income Source (i.e. employment, CalWORKS, child support, etc.)(Required)

Please check the center(s) you prefer:(Required)

Early Learning Center, San Mateo (3 months to 5 years)

First Step CDC, San Mateo (18 months to 5 years)

Haven CDC, Menlo Park (18 months to 5 years)

Leo J. Ryan CDC, South San Francisco (3 to 5 years)

Club Leo J. Ryan, South San Francisco (5 to 12 years)

Mission CDC, Daly City (3 months to 3 years)

87th Street CDC, Daly City (3 to 5 years)

Midway CDC, Daly City (3 months to 5 years)

Our Second Home CDC, Daly City (3 to 5 years)

Early Learning Eligibility Information Form

Fill out the Form

Early Learning Eligibility Information Form